Every finding on record at Willowcreek Rehab and Nursing

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and treat residents with respect and dignity for 3 of 12 (Residents # 62, Resident # 45, and Resident # 22 ) residents reviewed for dignity.The facility failed to prevent CNA E from standing over Resident# 62, Resident # 45, and Resident # 22 while assisting residents with eating their meal in the dining area.The facility failed to prevent CNA E from referring to Resident# 62, Resident # 45, and Resident # 22 who needed assistance with meals, as feeders.These failures could affect residents that require assistance with eating by placing them at risk of diminished quality of life and loss of their sense of self self-worth.BThe findings included:Review of Resident #62's Face Sheet dated 05/06/2026, reflected an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses including the following: dementia ( a general term for loss of memory, language, and problem solving skills severe enough to interfere with daily life, muscle wasting and weakness, anxiety disorder (Persistent worry and fear that interferes with daily life lasting for months).Review of Resident #62's Quarterly MDS, dated [DATE] reflected a BIMS score of 6 indicating severe cognitive impairment. The resident had difficulty focusing her attention, required substantial to maximal assistance with eating, but did not have a significant weight loss or gain.Review of Resident #62's Care Plan dated 4/18/26 reflected the following problems: Resident is on a Regular diet regular texture with thin liquids and is at nutritional and hydration risk related to dementia.Review of Resident #45's Face Sheet dated 05/06/2026 reflected a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses including the following: adjustment disorder with depressed mood ( excessive reaction to stress that involve negative thoughts, strong emotions, and changes in behavior), protein calorie malnutrition ( a condition resulting from inadequate intake of protein and calories) dementia ( a group of symptoms that affect thinking, memory, and social abilities), and anxiety disorder (a mental health condition characterized by excessive worry about every day issues affecting daily functioning and quality of life).Review of Resident #45's Quarterly MDS, dated [DATE] reflected that she was unable to complete the BIMS test, and had severe cognitive impairment with a long- and short-term memory problem. The resident had difficulty focusing her attention, required setup and cleanup assistance with eating, but did not have a significant wt loss or gain.Review of Resident #45's Care Plan dated 01/13/2026reflected the following problems: Resident is on a Regular diet regular texture with thin liquids and is at nutritional & hydration risk related to dementia. Resident has ADL Self Care and requires setup and clean up assistance with feeding, Resident is on a Regular with mech-Soft texture diet thin liquids and at nutritional and hydration risk related to dementia. Review of Resident #22's Face Sheet dated 05/06/2026 reflected a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses including the following: obesity, chronic oral aphthae (chronic ulcerations of the oral cavity and mouth that are painful), and decreased mobility and major depressive disorder with psychosis ( characterized by deep depression and loss of touch with reality).Review of Resident #22's Quarterly MDS, dated [DATE] reflected she was unable to complete a BIMS assessment , had a severe cognitive impairment with a long and short term memory problem. She continually exhibited inattention, and continually displayed disorganized thinking. She required maximal assistance with eating, had a significant weight loss of 5 percent or more in the last 30 days or 10 percent in the last 6 months and required maximal assistance with eating. Her weight was 208.Review of Resident #22's Care Plan dated reflected the following problems: Resident will grab food off of other residents' trays, from the food cart, and the trash can. Resident is on a Regular with mechanical soft texture diet thin liquids and at nutritional and hydration risk related to dementiaIn an observation on 05/04/2026 at 12:15 p.m., of the lunch meal in the secure unit dining room, CNA C was observed standing over Resident #62 and assisting her with eating her meal by placing food in her mouth with a utensil. Resident # 62 had to be redirected constantly in order to keep her seated at the bedside table where she was seated in the dining room.In an interview an observation on 05/05/2026 at 12/20/2026 at 12/30/2026 12:30 pm CNA E s was standing over a group of 5 residents in a corner of the dining room and was assisting Resident # 62, Resident # 45, and Resident # 22 eating their lunch meal. She stated there were 2 staff in memory care that day and there were usually 3 staff. CNA E stated there were 9 feeders , in the dining area for all meals. CNA E stated that she could not think of anything that she had done wrong during the meal service. She stated she did not think that there could have been a negative outcome for referring to resident's that needed assistance with eating as feeders or by standing over them and moving from one resident to another.In an interview on 5/05/2026 at 12:45 p.m. LVN F said staff should not stand over residents when they were assisting residents with their meals, they should sit at eye level and speak to the residents when they were feeding them. She stated residents should have been called by their preferred name and not nick names such as mama or labels such as feeders. She stated they could affect the residents by making them feel as if they were not treated as respected individuals.In an interview on 5/05/2026 at 12:30 p.m. the DON said staff should not stand over residents when they were assisting residents with their meals, they should sit at eye level and speak to the residents when they were feeding them. She stated resident's should be called by their preferred name and not nick names such as mama or labels such as feeders. The DON said it was a dignity issue. She stated she would do an in-service with CNA Eand all staff regarding feeding and do a competency check on all Staff for feeding a resident who cannot feed themselves.Record review of the policy dated February 12th, 2017, titled Promoting/ Maintaining Resident Dignity: dated 02/26/2020 did not mention dining.Record review of Resident Clinical skills check list titled Feeds client who cannot feed self-stated in part: Explains procedure to client speaking clearly, slowly, and directly maintaining face-to-face contact whenever possible. CNA sits in a chair facing the resident. Using spoon offers resident one bite of each food on tray telling the resident the content off each spoonful. CNA asks resident if they are ready for the next bite.

Based on observation, interview and record review the facility failed to ensure that residents were free of a med error rate of 5% or greater for 3 (Resident #10, Resident # 20 and Resident #25) of 5 residents reviewed for medication administration. The facility failed to ensure the medication error rate (11.5%) was less than 5%. This failure placed residents at risk of incorrect doses of medications and optimal therapeutic response. Findings included: Resident #10 Record review Resident #10's face sheet dated 5/6/26 revealed a [AGE] year-old female with an admission date of 12/12/2024. She had an active diagnosis of Dysphagia (difficulty swallowing) following cerebral infarct. Record review of Resident #10's physician orders dated 05/05/26 documented the following order: Acetaminophen (Tylenol) Oral Tablet 500 mg . Give 2 tablets via PEG-Tube every morning and at bedtime. During an observation on 05/05/2026 at 9:00 AM LVN A gave Tylenol 160 mg/5 ml gave 30 ml. Resident #20 Record review of Resident #20's face Sheet dated 05/06/2026 revealed a 64 -year-old female with a most recent admission date of 11/17/2025. Resident had the following diagnosis: Diabetes Mellitus. Record review of Resident #20s Physician Orders dated 05/05/2026 revealed: Insulin Aspart Flex Pen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) Inject 12 unit subcutaneously before meals for hyperglycemia Do not give if not eating or BS less than 60.Must give with 15minutes Inject as per sliding scale: if 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 400 = 15 units, subcutaneously before meals and at bedtime Inject subcutaneously before meals and at bedtime related to Diabetes. In an observation on 05/06/2026 at 10:34 AM, RN D checked Resident #20's blood glucose and obtained a reading of 317. Per resident sliding scale, orders stated ( Blood sugar 301 -350 give 12 units Aspart Insulin) LVN gave Resident #20 12 units of Aspart insulin SQ and 12 units of Aspart Insulin to = 24 units . In an interview on 05/05/26 at 2:46PM with the Regional Nurse, she said her expectation for nurses was to check the resident's blood sugar and administer short acting insulin within 15 minutes of a meal and administer the correct dosage of all medications and the correct form according to the package label and the physicians orders. She said the adverse outcome for residents could be not getting the correct dose of insulin and low blood sugar. She stated she would in-service the RN D and other nursing staff. She stated she did not know why the errors occurred. She also stated that the nurse had rechecked the blood sugar before lunch and her blood sugar was 300. Resident #25 Record review on 05/06/2026 of Resident # 20's face sheet dated 05/06/26 revealed a 79- year old female with an admission date of 8/18/2025. She had a diagnosis of unspecified diastolic congestive heart failure (a condition that results when the heart's left ventricle stiffens and cannot relax normally preventing it from adequately filling with blood during heart beats Record review of Resident #25's physician orders dated 05/05/26 revealed an order for Metoprolol Tartrate 25 mg 1/2 tablet to equal 12.5 mg. twice daily po. During an observation on 5/5/25 at 9:00 a,m, LVN A gave Metoprolol Succinate (extended release) 1/2 to equal 12.5 mg tablet po. In an interview on 05/05/26 at 4:56PM with the DON, she said expected a fast-acting insulin that was administered per sliding scale according with the dosage indicated by the blood sugar reading that corresponded to the sliding scale no more than fifteen minutes before bedtime. She stated that failure to administer any medication to a resident in the correct form or dosage could lead to adverse side effects or an unintended therapeutic response. She stated there was no negative outcome to the resident and that the nurse had rechecked the blood sugar before lunch and her blood sugar was 300. Record review of facility policy titled Medication Administration and documenting guidelines dated 04/06/2023 revealed the following in part: Medications are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Verify labels accurately reflect the physician orders on the Electronic Medication Administration record prior to administering medications verify medication accuracy by checking the medication with the EMAR. Administer the medication according to the physician order.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 refrigerator in the secure unit. The facility failed to ensure the refrigerator on the secure unit that was used for patient snack storage was clean and temperatures were being checked and recorded. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated. The findings included:In an observation on 5/5/26 at 12:09 pm in the secure unit lobby, there was a small refrigerator that was soiled with dried food, spilled punch in the bottom, dust and dirt, and the ice had built up in the top freezer portion, and it needed to be defrosted on the inside. On the outside it was covered in dust on the top of the refrigerator. There was no temperature logs attached and no evidence of daily temperatures being taken. In an interview and observation with the DON on 5/5/26 at 12:20 pm, she said the night nurses were responsible for cleaning the refrigerator and taking the temperatures. The temperature log was observed at the nurse's station for the month of May 2026, and it was blank. She did not know why it was not filled out. She said a potential negative outcome would be infection control concerns.Record review of the facility policy Frozen and Refrigerated Food Storage, dated was revised 11/16/2017, revealed the following [in part]: Policy: PHF/THC (Potentially hazardous/Time temperature control for safety) foods will be properly refrigerated or frozen to reduce the potential for food borne illness and maintain product integrity. These procedures are applicable to pantry refrigerators and freezers of nursing units, if food or supplements for resident consumption and contained in those refrigerators and/or freezers. Procedure:2. Refrigerator and freezer temperatures should be checked and logged a minimum of twice daily, once in the morning and once in the evening. The purpose of this is to be able to react quickly if a unit is having a problem. Temperatures must be recorded on the appropriate temperature log. Record review of the Food and Drug Administration Food Code, dated 2022, specified [in part]:4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a sanitary, and comfortable environment for 5 of 20 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], 104 and the East Conference Room) rooms observed for environmental conditions. The facility failed to ensure rooms 101,102, 103, 104 and the East side Conference Room sinks had hot water. These failures could place residents at risk for diminished quality of life, discomfort, and safety. Findings included: During an observation on 05/05/2026 at 12:16 p.m., East Side room [ROOM NUMBER] the water temperature in the sink with shared toilet room with room [ROOM NUMBER] hot water felt cold. The temperature was taken and the hot water temperature was 79.7 degrees F, after water was left running for 1 minute. During an observation on 05/05/2026 at 12:21 p.m., East Side room [ROOM NUMBER] the water temperature in the sink shared with room [ROOM NUMBER], the hot water felt cold. The temperature was taken and the hot water temperature was 78.4 degrees F, after water was left running for 1 minute. During an observation on 05/05/2026 at 3:03 p.m., East Side room [ROOM NUMBER] water temperature in the sink shared with room [ROOM NUMBER] the hot water felt cold. The temperature taken and the hot water temperature was 86.3 degrees F, after water was left running for 1 minute. During an observation on 05/05/2026 at 3:05 p.m., East Side room [ROOM NUMBER] water temperature in the sink shared with room [ROOM NUMBER] the hot water felt cold. The temperature was taken and the hot water temperature was 86.2 degrees F, after water was left running for 1 minute. During an observation on 05/05/2026 at 3:22 p.m., the East Side conference room at the end of the hallway's toilet room sink hot water was not hot. The temperature was taken and the hot water temperature was 87.0 degrees F, after water was left running for 1 minute. During an observation on 05/06/2026 at 9:23 a.m., East Side room [ROOM NUMBER] the water temperature in the sink shared with room [ROOM NUMBER] the hot water felt cold. Temperature taken and the hot water temperature was 66.3 degrees F, after water was left running for 1 minute. During an observation on 05/06/2026 at 9:29 a.m., East Side room [ROOM NUMBER] water temperature in the sink shared with room [ROOM NUMBER] the hot water felt cold. The temperature was taken and the hot water temperature was 77.3 degrees F, after water was left running for 1 minute. During an interview on 05/05/2026 at 12:11 p.m., LVN A stated she notified the maintenance director that morning verbally that the water was not coming up to temperature. She stated she did not know if the maintenance director had checked the water temperatures. She stated she would want water to be hot in the sink of the room if she resided at the facility. During an interview and observation on 05/06/2026 at 9:25 a.m., MA B stated she would expect hot water to be available in the bathroom. She stated that sometimes if you ran the cold water, it would help the water to flush through the lines and the hot water would get to the sink faster. She was observed running the cold water, and the hot water temperature did not improve. She stated she was not aware that the hot water was not working or how long it had not worked. During an interview on 05/06/2026 at 9:38 a.m., the maintenance director stated she was taking temperatures of the water in room weekly and had those logs. She stated she had not been told that the water was not hot in rooms 101-103 or 102-104. She stated last year, the facility had issues with the hot water being too hot. She stated the temperature needed to be between 100 and 110 in the resident rooms and shower rooms. She stated the facility had put in an aquastat (a device that senses and controls water temperature) to help regulate that the temperatures would not be too hot. She stated the facility used a loop system and if the hot water heater was not functioning the hot water in the shower would not be the correct temperature. She stated she would call the plumber to find out why the resident rooms at the end of the hall did not have hot water. During an interview on 05/06/2026 at 9:40 a.m., the Regional Clinical Nurse stated she would expect the water in the sinks in the restrooms to be hot. She stated the aquastat would not allow for the water to not get above 106 degrees but would not make the water not flow to the rooms on the end of the hallway. She stated a plumber was scheduled to look at the water situation that afternoon at 2:00 p.m. During an interview on 05/06/2026 at 2:54 p.m., the ADMN stated he expected residents to have access to hot water in the bathroom of their rooms. He stated the facility had plumbers out to correct the issue and he was told they would have to replace a check valve. He stated the maintenance director was checking the room temperatures weekly in all the rooms and had not had a temperature reading that was out of range. He stated he had not been informed of any resident rooms not having low water temperatures before this morning. He stated not having hot water could lead to residents being upset. Record review on 05/06/2026 of the facility's weekly water temperature logs, dated April 2026, reflected the water temperatures on the East Side of the building had been taken on 4/3/26, 4/10/26, 4/17/26, 4/24/26, and 4/30/26. Rooms 101 / 103's water temperatures ranged from 100 - 103 in April 2026. Rooms 102 / 104's water temperature ranged from 100 - 103 in April 2026. No temperatures observed were lower than 100. The administrator was asked for a policy on hot water on 05/06/2026 and a policy was not provided by exit.

Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 5 of 5 residents (confidential residents) reviewed for resident rights.The facility failed to ensure staff distributed mail received on Saturdays to the residents. This failure could result in residents not receiving mail in a timely manner and a diminished quality of life.Findings included:During a confidential group interview on an undisclosed date and time, 5 of 5 members in the group stated they did not receive mail on Saturdays because the girls in the offices did not work on Saturdays. They stated the mail was delivered Monday through Friday.During an interview on 05/06/2026 at 1:52 p.m., the AD stated she was responsible for getting the mail for the residents during the week Monday through Friday. She stated before today there was no person that was assigned to get the mail on the weekends. She stated moving forward, the plan was for a nurse to go and get the mail out of the mailbox, separate the business office mail out and give the residents their mail on Saturdays. She stated she would come up to the facility on Saturday if needed to administer mail but had never been told to. During an interview on 05/06/2026 at 2:21 p.m., the DON stated she expected residents to get mail on Saturdays. She stated the facility was planning on having a Saturday nurse pass out mail on the weekend and the weekend supervisor to make sure the mail was passed out. She stated the facility only had one key for the mailbox and they were getting another one made for the weekend staff. She stated residents having to wait until Monday for their mail could possibly cause depression from not getting mail when expected.During an interview on 05/06/2026 at 2:54 p.m., the ADMN stated mail should have been delivered on Saturdays. He stated there was only one key and the AD had it. He stated moving forward, they would have a key made for the nurses working on Saturdays. He stated the Saturday nurse could then collect mail out of the mailbox and deliver it to the residents. He stated he was not aware the mail was not being delivered and no one had brought it to his attention. He stated no residents had complained about not receiving mail to him. He stated not delivering the mail could have caused residents to be upset about having to wait until Monday for their mail when they were expecting it on Saturday. Record review of facility policy titled, Resident Right to Privacy in Communication, dated 2/10/2021, reflected The facility will honor the resident's right to privacy in written communications including the right to: a. Send and promptly receive mail that is unopened.The social service designee, or another designated staff member, will ensure each resident receives any mail addressed to that particular resident promptly.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #70) of 3 residents reviewed for infection control.The facility failed to implement Enhanced Barrier Precautions for Resident #70 who had an Enhanced Barrier Precautions sign posted on her room door. This failure could affect residents and place them at risk for cross contamination and infections.The findings included:Record review of Resident #70's admission Record, dated 5/8/26 revealed a [AGE] year-old female with an original admission date of 1/21/23 with the latest admission date of 3/16/26. Her diagnoses included embolism and thrombosis of arteries of the lower extremities (blood flow to the legs is blocked) and cerebral infarction (stroke-blood clot in the artery in the brain). Record review of Resident #70's Quarterly MDS, dated [DATE] revealed the resident had a BIMS score of 14 (cognitively intact). Section M - Skin Conditions revealed the resident had a stage 2 pressure ulcer. Record review of Resident #70's Physician Order Summary, dated 5/8/26 revealed the following orders: A. Implement Enhanced Barrier Precautions per CDC guidance for: Wound to Right Ankle. Gown and gloves required for high-contact resident care activities, including but not limited to: Dressing, bathing, and personal hygiene Wound care Device care Toileting and incontinence care Transferring, or extensive physical contact Hand hygiene before and after all resident contact. B. Cleanse abrasion to right second toe with normal saline or wound cleanser every day. C. Cleanse abrasion to right great toe with normal saline or wound cleanser every day. D. Cleanse unstageable pressure injury to right outer ankle with normal saline/ wound cleanser, apply collagen powder with anasept wound gel or wound gel and cover with padded dressing daily. In an observation and interview on 5/5/26 at 9:20 am revealed RN C entered Resident #70's room to perform wound care. There was an Enhanced Barrier Precaution sign on the door, and personal protective equipment inside of the room. The Wound Care Nurse provided wound care without donning a gown. At the end of the procedure, the RN C said she forgot to put on a gown due to the resident being on Enhanced Barrier Precautions. She said a potential for the failure was that infection could spread. In an interview on 05/05/2026 at 9:45 am, the DON said it was her expectation for the staff to glove and gown when they provided care to residents who were on Enhanced Barrier Precautions. She said RN C said she forgot to put on a gown. She said the failure had the potential to spread infection. Record review of the facility's policy titled Infection Prevention and Control Program, dated as revised 11/6/24, stated [in part]:Policy Explanation and Compliance Guidelines:6. Enhanced Barrier Precautions. EBP was used in conjunction with standing precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. B. During high-contact resident care activities:*Wound care: any skin opening requiring a dressing.Gloves and gowns prior to the high-contact care activity.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure staff practiced appropriate hand hygiene during meal prep.2. The facility failed to ensure staff wore effective hair restraints while in the kitchen area. These failures could place residents who received food from the kitchen at risk of cross contamination and food borne illness.The findings include: During an observation on 12/18/2025 at 10:35 a.m., observed Dietary Aide A as she wore a hair net that did not fit properly on her head. Dietary Aide A had approximately two (2) inches of hair across her forehead exposed and approximately four (4) inches of hair on the back of her neck exposed from the hairnet that hung down her neck. During an observation on 12/18/2025 at 10:40 a.m., observed [NAME] B's hair net did not cover her entire head and she had approximately two (2) inches of hair exposed around the circumfuse of her entire head. During an observation on 12/18/2025 at 10:45 a.m., observed [NAME] B enter the pantry with a box of corn starch, placed the item on the shelf, and exited the pantry. [NAME] B removed a large cooking sheet and placed the item on the counter. Cooked B picked up a stack of small dessert bowls and placed the bowls on the cooking sheet. [NAME] B touched the inside of the bowls with her thumb as she placed them on the cooking sheet. [NAME] B picked up a scoop and put bread pudding in each bowl. [NAME] B picked up a container of white liquid and drizzled over the pudding with a spoon. Observed [NAME] B's thumb inside the container where she was holding the container. [NAME] B was not wearing gloves. [NAME] B picked up the cooking sheet and moved the item over to the side. [NAME] B picked up a washcloth from a bucket of liquid from under the counter and wiped down the counter and placed the cloth back into the bucket. [NAME] B scratched the left side of her forehead where her hair and hair net were located and then picked up another cooking sheet and placed dessert bowls on the cooking sheet. [NAME] B did not wash her hands during this time. [NAME] B picked up a scoop and put bread pudding in each bowl. During an observation on 12/18/2025 at 10:57 a.m., [NAME] B exited the kitchen. During an observation on 12/18/2025 at 11:10 a.m., [NAME] B entered the kitchen and did not wash her hands. She was observed as she picked up the puree container and placed the container on the puree machine. [NAME] B picked up a stack of small bowls and placed them on the counter. [NAME] B touched the inside of the bowls with her thumb as she separated the bowls and placed each bowl on the counter. During an interview on 12/18/2025 at 11:25 a.m., Dietary A said she knew her hair was not covered completely with her hair net, but she had difficulty keeping her hair inside the net. Dietary A said the hairnets provided by the facility were difficult to use and at times slipped back and her hair came out. Dietary A said she was aware hair could fall into the food and could cause contamination. Dietary A said she would not want anyone to eat food with hair in it and hair in food could cause the food to be unappetizing. During an interview on 12/18/2025 at 12:33 p.m., the Dietary Manager said her expectations were for the staff to serve good quality food. The Dietary Manager said hair that was not covered by a hair net was unacceptable and she would work on the issues. The Dietary Manager said uncovered hair could cause the negative outcome of hair in the food and cross contamination. The Dietary Manager said the staff not washing their hands was unacceptable and did not meet her expectations. The Dietary Manager said she would re-educate the staff to prevent future incidents. The Dietary Manager said hand washing was important to prevent cross contamination and food borne illness. During an interview on 12/19/2025 at 2:23 p.m., the DON said she expected the expected the kitchen staff to follow policy and wash their hands when they first came on duty and if they left the kitchen, to wash their hands again upon return. The DON said the not washing hands per policy did not meet her expectations and training and in-services would be completed. The DON said not using proper hand washing protocol was the number one method of how germs were spread in the kitchen, which could cause illness to all residents and others who ate out of the kitchen. During an interview on 12/19/2025 at 9:34 a.m., [NAME] B said she had been trained on appropriate hand washing and was aware that she did not wash her hands enough during the observation. [NAME] B said she was nervous and forgot. [NAME] B said she when she did not wash her hands and touched the inside of the residents' bowls, she could spread germs and cause illness. [NAME] B said she realized why all her hair should be inside her hair net and she would be more aware. [NAME] B said the purpose of wearing a hair net was to keep her hair from falling into the food. [NAME] B said if someone ate the contaminated food, they could become ill, or the food would be unappealing. During an interview on 12/19/2025 at 10:53 a.m., the Interim Administrator said his expectation was for the facility to serve good food that met the nutritional needs of the residents. The Interim Administrator said his expectation was for the kitchen staff to wash their hands appropriately and to follow the facility policies to prevent any illness with the facility. Record review of the facility's policy, Food Safety and Sanitation Plan, dated 07/22/2021, revealed the facility basis of control for the policy would be personal hygiene practices.- Thorough hand washing was required, but not limited to, the following situations:A. starting a work shiftB. after using the restroomC. after handling raw food productsD. after touching hair or faceE. after the use of any chemicals

Based on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 residents (Resident #'s 2 and 4 ) reviewed for accuracy of records, in that: RN A failed to document the wound care for Resident #2's open areas to his right and left buttocks on 4/12/25 during the 6 AM to 6PM shift. RN A failed to document that Resident # 2 had a privacy bag on his catheter bag , a catheter securement device to hold his catheter tubing in place, and that he had a size 16 French to beside drainage and catheter care was administered during the 6 AM to 6 PM shift on 4/12/25. RN B failed to document the wound care for Resident #4's open areas to her right and left buttocks on 4/12/25 during the 6 AM to 6 PM shift. LVN B failed to document the wound care for Resident #2's open areas to his right and left buttocks on 4/24/25 during the 6 AM to 6 PM shift. LVN B failed to document that Resident #2 had a privacy bag on his catheter bag , a catheter securement device to hold his catheter tubing in place ,that he had a size 16 French catheter to beside drainage and catheter care was administered during the 6 AM to 6 PM shift on 4/24/25. LVN B failed to document the wound care for Resident #4's open areas to her right and left buttocks on 4/24/25 during the 6 AM to 6 PM shift. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care. The findings included: Review of Resident #2's electronic face sheet reflected the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included: hemiplegia ( paralysis on one side of the body), and prostate cancer. Review of Resident #2's care plan last revised 7/8/24 reflected: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Bed Mobility: dependent X2 Transfers: dependent assist of 2 [mechanical] lift Eating: supervision Toileting: Dependent Ambulation: NA Wheelchair: supervision independent mobility in electric wheelchair Dressing: Dependent on staff x 1 Personal Hygiene: Dependent on staff x1 Resident has a urinary catheter and is at risk for urinary tract infections and injury. Urinary catheter related to: Obstructive & Reflux Uropathy (urinary tract condition that occurs when urine flow is obstructed, either structurally or functionally) The resident will be/remain free from catheter-related trauma and complications through next review date. Catheter care: as ordered Device: indwelling foley cath. 16Fr Catheter cover: privacy bag while up in chair Monitor for and report to the physician any signs or symptoms of a urinary tract infection such as pelvic pain, burning with urination, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, urinary frequency, foul smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. Revised 8/15/24. Resident has moisture associated skin damage to his buttocks 26 x 30 cm clean with normal saline or wound cleanser revised 7/11/24 Review of Resident #2's 0rder recap report dated 4/20/25 reflected: Cleanse moisture associated skin damage to buttocks with wound cleanser, pat dry, apply collagen flakes, cover with silicone foam dressing every day until healed, dated 2/13/25. 16 French catheter with 30 cc bulb to gravity bedside drainage. Perform catheter care every shift Review of Resident #2's electronic progress notes reflected: 04/02/2025 2:53 pm noted pressure wound to sacrum measuring 2 by 4 cm, signed by wound care nurse. Record review of the treatment administration record for Resident #2 for the dates 4/1/25 to 4/30/25 reflected the following: No documentation on 6Am to 6 PM shift on 4/12/25 and 4/24/25 for the following : Treatment for moisture associated skin damage to right buttocks Treatment for moisture associated skin damage to the left buttocks Catheter privacy bag in place in bed or chair. Catheter securement device in place Urinary catheter to bedside drainage Review of Resident #4's electronic face sheet reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included: right side hemiplegia ( paralysis on one side of the body), and aphasia ( inability to understand or produce speech). Review of Resident #4's care plan revised 4/29/25 reflected: The resident has the following acute skin issue: open areas caused by skin trauma- Left superior buttock Left inferior buttock Right Superior buttock Right middle buttock #1 Right middle buttock #2 Right inferior buttock The resident's skin issue will resolve by the next review date. Administer analgesics as needed for discomfort or pain. If necessary provide pain management before care tasks such as repositioning or dressing. Encourage the resident not to scratch, pick, or rub the affected area. Monitor for signs of infection such as increased drainage, foul odor, pain, swelling or redness at the site. Report any findings to the practitioner. Treat the skin issue per order. Review of Resident #4's 0rder recap report dated 4/30/25 reflected: Cleanse moisture associated skin damage to right and left buttocks with normal saline or wound cleanser and pat dry with gauze. Apply triad zinc paste to compromised skin and apply calcium alginate over and cover with foam border dressing. Record review of the Treatment administration record for Resident #4 for the dates 4/1/25 to 4/30/25 on the 6 AM to 6 PM shift reflected the following: No documentation on 4/12/25 and 4/24/25 for the following : Treatment for moisture associated skin damage to right buttocks Treatment for moisture associated skin damage to the left buttocks Catheter privacy bag in place in bed or chair. Catheter securement device in place Urinary catheter to bedside drainage During an interview with RN A on 4/30/25 at 1:45 PM, she stated she did perform wound care on Resident #2 and Resident # 4 on 04/12/25. She stated she did not recall what happened but stated she must have been called away from her documentation and forgot to document the Catheter privacy bag in place in bed or chair, Catheter securement device in place, and catheter care urinary catheter to bedside drainage. She stated this was all included in the care she had given Resident # 2 and Resident #4. She stated she always did her treatments, and she should document her treatments when they were done in order to avoid an error. She stated failure to document accurately could cause an error in the resident's care. During an interview with LVN B on 4/30/25 at 1:55 PM, she stated she did perform wound care on Resident #2 and Resident # 4 on 04/24/25. She stated she did not recall what happened but stated she must have gotten busy and just forgot to document the care she had given Resident # 2 and Resident #4. She stated she should always document care when it was done. She stated failure to document accurately could cause an error in the resident's care. During an interview on 04/30/25 at 03:17 PM, the Acting DON (who was also the treatment nurse) stated her expectation was for documentation to be completed accurately. She stated she felt the error was from staff not paying attention to what they were doing, and not documenting their work. She stated all nurses would be in-serviced regarding documentation. She stated the negative outcome could be residents not receiving the care that they need. Review of facility policy titled, Administration and Documentations Guidelines, revised 4/6/24, reflected in part: document PRN medication and treatment administration on the EMAR or ETAR along with the reason immediately following administration. Document effectiveness of the intervention on the EMAR/ETAR as indicated. Review the EMAR/ETAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and support services provided according to the physicians orders.

Based on observations, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1(Resident # 4) of 2 residents observed for wound care. The facility failed to ensure the wound care nurse washed or sanitized her hands between glove changes while performing incontinent care and wound care on Resident #4. These failures could place residents at risk of infections. The findings included: Review of Resident #4's electronic face sheet reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included: right side hemiplegia ( paralysis on one side of the body), and aphasia (inability to understand or produce speech). Record review of Resident #4's Annual MDS assessment dated [DATE], revealed the following: Section K (Skin): Resident has moisture associated skin damage; Section H: resident is always incontinent of bowel and bladder. Record review of Resident #4's care plan dated revised 4/29/25 reflected the following information: The resident requires Enhanced Barrier Precautions d/t Wounds. The resident will remain free from active infection with MDROs through the review date. Educate the resident and family on the reason and procedure for enhanced barrier precautions. Ensure EBP signage is posted outside the resident's room and above the head of the resident's bed . Treat the skin issue per order. Ensure PPE is available for use on the resident; Notify the physician of any S/S of active infection; Wear gown and gloves during high-contact resident care activities. In an observation of peri care and wound care on Resident #4 on 4/30/25 at 10:00 AM , the wound Care Nurse/Acting DON entered Resident #4's room. There was an enhanced barrier precautions sign on Resident #4's door. She did not wash her hands but stated she had washed her hands prior to entering the room. She donned gloves and a gown. She removed a urine soiled brief from Resident #4 and disposed of the brief in the trash at bedside . She performed incontinent care, which included cleansing the areas around the urethra and then the anal area. She changed gloves but did not perform hand hygiene before applying clean gloves. She removed the soiled dressings and changed gloves again without performing hand hygiene. She cleansed the wound and performed the wound care as ordered, then removed her gloves and applied new gloves without performing hand hygiene. She applied a clean dressing and arranged the resident's covers and bed side table before leaving the room. In an interview with the wound care nurse/acting DON on 4/30/25 at 10:15 AM she stated she realized now that she did not perform hand hygiene between glove changes, and she should change gloves and perform hand hygiene when going from a dirty area to a clean area. She stated she failed to perform hand hygiene at the proper time because she was nervous. She stated failure to perform hand hygiene between glove changes could result in increasing the resident's risk of infection. She stated the resident was on enhanced barrier precautions because she had chronic wounds. During an interview on 4/30/25 at 12:45 PM the RNC stated that her expectation was that hand sanitizer be used by all personnel as part of infection control between glove changes and after resident contact. She stated the Wound Care Nurse was extremely nervous and that was why the failure occurred. She stated a negative resident outcome of the failure to perform hand hygiene would be infection. Review of the facility policy titled Hand Hygiene dated revised 2/11/22 revealed the following: all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by hand washing with soap and water, or the use of an antiseptic hand rub (also known as alcohol-based hand rub). The use of gloves does not replace hand hygiene if your task requires gloves. Perform hand hygiene prior to donning gloves and immediately after removing gloves. Hand hygiene table: Hand hygiene should be used before applying and after removing personal protective equipment, including gloves. T

Based on observations, interviews, and record review, the facility failed to maintain hot water below 110 F for 5 of 8 (Resident #60's sink, RM17 E sink, East Hall shower room sink, Resident #168, Resident #167, and Resident # 14's shared sink and RM 24 E sink) bathroom reviewed for water temperature. 1. The temperature of sink in RM 17E was 150 F. 2. The temperature of the East Hall Shower Room Resident 150 F. 3. The temperature of Resident #168, Resident #167, and Resident #14's shared sink was 140 F. 4. The temperature of Resident #60's sink was 136.4 F. 5. The temperature of sink in RM 24E was 125.2 F. 6. The shower water temperature fluctuated, becoming hotter during use for Resident #23 and Resident #1 An Immediate Jeopardy (IJ) situation was identified on 02/25/2025. The IJ template was provided to the facility on [DATE] at 5:00pm. While the IJ was lowered on 02/27/2025 at 5:11 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of a pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk for 3rd degree burns causing serious injury, serious harm, hospitalization s, impairment, and/or death. Findings included: Resident #60 Review of Resident #60's Face Sheet revealed an [AGE] year-old female admitted on [DATE]. Resident #60's medical diagnoses included psychotic disorder with hallucinations, blood clots in the legs, back pain, difficulty walking, right shoulder pain, weakness, night terrors, and impaired cognition. Review of Resident #60's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 07 (severe impairment). During an observation and interview on 02/24/2025 at 3:45 PM, Resident #60's Family Representative stated the water in the restroom was sometimes too hot. The temperature was taken of hot water, and it was under 110 F. Resident #168 Review of Resident #168's Face Sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #168's medical diagnoses included COPD (Chronic Obstructive Pulmonary Disease), alcohol dependence, nicotine dependence chronic pain, respiratory failure, and homelessness. Review of Resident #168's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 15 (cognitively intact). During an observation and interview on 02/24/2025 at 3:08 PM, Resident #168 was sitting on his bed in his room. He stated the water gets hot sometimes, and it will burn you. Resident #168's water was warm to touch. Resident #23 Review of Resident #23's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admitted [DATE]. Resident #23's medical diagnoses included muscle weakness, insomnia, edema (swelling), urinary tract infection, dependent on renal dialysis, mild dementia, diabetes, and lack of coordination. Review of Resident #23's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 13 (cognitively intact). During an interview on 02/25/25 at 3:04 PM, Resident #23 stated the shower water was sometimes too hot having to readjust the water temperatures often. She stated she needed help with the set-up for her showering but then would bathe herself. She stated that during her shower the water temperature would increase. During an observation on 2/25/2025 at 4:34PM, the water in RM 17 E sink was hot to touch and steam was observed coming off water, the water temperature was 150 F; at 4:41 PM the East Hall shower room sink was at 150 F; and at 4:43 PM Resident #168 Resident #167, and Resident # 14's shared sink was 140 F. During an observation and interview on 02/25/2025 between 5:40 PM and 6:00 PM, the ADMN checked the temperature of random resident sinks to test temperatures. The ADMN stated water temperatures should be between 100 F and 110 F and that if above 110 F degrees it could have led to injury. The ADMN stated the temperature of water in Resident #60's sink was 136.4 F and RM 24E was temperature of 125.2 F. During an interview on 02/25/2025 at 7:05 PM, Resident #1 stated her water in her sink gets really hot. Resident #1 stated she would turn on her cold water to make the water cooler. Resident #1 stated she had not made a complaint about how hot the water was because she could just turn her cold water on. She stated that during her shower once the temperature was regulated, the water would get hotter at times, and she would have to ask for assistance to readjust the water. During an interview on 02/25/2025 at 5:00 PM, the MM stated the facility had been having issues with the temperature gauge on the boiler mixer since the plumber had installed a new pump, that circulated water to the facility. The MM stated the arrow on the temperature gauge continued to bounce back and forth within the red range and above the red range and did not know what it meant or why it was doing it. The MM stated the plumber had been in and out of facility the past few months. The MM stated he used a digital probe thermometer and, the last time he tested water temperatures were on 2/21/2025. The MM stated he picked random rooms and all shower rooms to check weekly and documented temps in his electronic system. The MM stated he typically took the water temperatures in the afternoon after resident showers. The MM stated he had not received any complaints of the water being too hot. The maintenance stated water temperatures were not to be over 110 F. During an interview on 02/25/2025 at 6:30 PM, the DON stated if the water temperatures were over 110 F, it was too hot. The DON stated any temperature over 110 F would be a risk for burn. During an interview on 02/25/2025 at 6:33 PM the Regional Nurse stated in her nursing judgment anything over 130 F would be dangerous and could have caused the resident injury. The Regional Nurse stated water temperatures should have been below 110 F. During an interview on 02/26/25 at 11:15 AM one of the plumbers, working at the facility, stated he had been at the facility numerous times. He stated the previous maintenance man had stated they had been having issues for over 5 years. They first replaced the mixing valve, several months ago. He stated that they would adjust things and it would work for a while and then have to come back and check things again. He replaced the pump that circulated the water into the building previously and they were still having issues with how the water was being distributed through the building. The plumber stated he was going to add a second pump to see if this would help with how water was being distributed. The plumber stated this could have caused the water from the mixer to not stabilize. He stated there should have been a little fluctuation with the temperature on the gauge but should not have been fluctuating in and out of the red zone. He stated when the arrow was out of range it could have meant the water was over 140 F. During an interview on 02/27/25 at 1:35 PM the ADMN stated his expectation was that water temperatures should not exceed 110 F. The ADMN stated the MM was responsible to monitor water temperature and he was to report to the AMDN. The ADMN stated the effect on residents of water being too hot was it could have injured residents due to scalding. The ADMN stated what led to the failure was the actual boiler and chiller through the years have been co-mingled and the system began to fail. The ADMN stated in reality the plumbing companies have been monitoring the situation and the issues got ahead of them. Record review of the facility maintenance log between January 31, 2025, and February 24, 20205 there was no time stamp of when temperatures were taken. Not all rooms had temperature taken and the same rooms were checked each week. There were 12 out of 33 resident rooms where temperatures had not been taken during the four-week time frame. The following dates had temperatures above 110 F: on 01/31/2025 RM 27E was 110.1 F and the East Hall Nurses Station was 110.7 F; on 02/06/2025 the East Hall shower room was 111 F, the East Hall Nurses Station was 110.3 F and RM 19 East and RM 21 East shared bathroom was 110.7 F; on 02/18/2025 the East Hall Nurses Station was 110.4 and RM 19 East and RM 21 East shared bathroom was 110.5. Review of US Consumer Product Safety Commission Avoiding Tap Water Scalds accessed on 02/26/2025 at http://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cpsc.gov/s3fs-public/5098.pdf revealed: Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140-degree water or with a thirty second exposure to 130-degree water. Even if the temperature is 120 degrees, a five-minute exposure could result in third-degree burns. This was determined to be an Immediate Jeopardy (IJ) on 02/26/2025 at 4:31 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 02/26/2026 at 5:00 PM. Record review of Plan of Removal accepted on 04/27/2024 at 1:33 PM reflected the following: Tag Cited: F_689 Issue Cited: Failure to maintain an environment that was free from accidents and hazards 1. Immediate Action Taken A. On 2/25/2025 the maintenance director turned off all hot water in all resident rooms B. On 2/25/2025 all shower rooms were secured by the Maintenance Director with key codes/or pad locks and do not enter signs were placed on the door taking them out of service until further notice. C. On 2/25/2025 all staff were in-serviced that hot water was turned off in resident rooms, and all shower rooms were secured and out of service D. On 2/26/2025 the hot water issues were fixed by the Plumbing company at 4:30 pm. The issues were fixed by adding 2 new recirculating pumps, by re-routing the plumbing to the mixing valve, and by adding 2 new thermostats (1 to the water coming into the mixing valve, and 1 coming out of the mixing valve). The Maintenance Director completed testing all hot water in all resident rooms and shower rooms at 7:00 pm with no hot water temperatures found to be above 110 degrees. E. On 2/26/2025 the DON/Designee completed head-to-toe skin assessment for residents 60, 168, 167, and residents #14 and no skin issues identified F. On 2/27/2025 at 7:09 am, while testing hot water Temps. It was noted that the facility had hot water temps. Above 110 degrees, so all hot water was again immediately turned off. The Plumbing Company was immediately notified. G. On 2/27/2025 all staff were alerted that hot water would again be shut off to the facility. 2. Identification of Residents Affected or Likely to be Affected: A. On 2/26/2025 the DON/Designee completed head-to-to-toe skin assessment for all other residents throughout the facility, and no issues identified. This was completed on 2/26/2025 at 5:43pm. 3.Actions to Prevent Occurrence/Recurrence: A. On 2/25/2025 the DON/Designee began in-service education with all staff on: This training was completed at 7:00 pm on 2/25/2025 and no staff were allowed to work until they complete this training. Hot water is being turned off on all resident sinks, shower rooms are not to be used, do not turn on hot water in resident rooms. This was completed on 2/25/2025, and no staff were allowed to work until they completed this education. Ensure doors to shower rooms are kept closed at all times to prevent residents from entering unattended. This was completed on 2/25/2025, and no staff were allowed to work until they completed this education. Starting 2/26/2025 This education will be provided for all new hires and any agency staff going forward as part of new hire orientation. B. On 2/26/2025 The Regional Nurse consultant provided 1:1 in-service with the Maintenance Director regarding the hot water system and taking and recording hot water temperatures: Every hour x 4 hours, then twice daily x 3 days, then daily x 7 days then resume the weekly water temp. testing. If at any time the hot water temp. exceeds 110 degrees, the hot water will be turned off, The Plumber will be notified for repairs/services, and the monitoring process above will continue until the hot water temperatures remain between 100 and 110 degrees. On Schedule of checking hot water temps. Weekly, rotating rooms, bathrooms etc., ensuring that all rooms and shower room hot water temps are taken and recorded during the month and hot water temperatures remain between 100 and 110 degrees. C. On 2/26/2025 DON/Designee start in-service training with all staff related to: a. Hot water is being turned off on all resident sinks, shower rooms are not to be used, do not turn on hot water in resident rooms. This was completed on 2/26/2025, and no staff were allowed to work until they completed this education. b. Ensure doors to shower rooms are kept closed at all times to prevent residents from entering unattended. This was completed on 2/26/2025, and no staff were allowed to work until they completed this education. c. To turn hot water off immediately and notify charge nurse if at any time water temps. Feel too hot. The nurse in charge will immediately contact the facility administrator so this issue can be addressed immediately. This was completed on 2/26/2025 and no staff were allowed to work until they complete this education. D. All hot water temperature logs will be reviewed daily by the Facility administrator/Designee in the morning meeting to validate facility remains in compliance and no residents are affected related to water temperatures being too hot. E. If at any time during hot water temperature monitoring, any temperature reading is above 110 degrees, the hot water will be shut off to all resident rooms and shower rooms, a plumbing company will be notified to address the issue, and the facility will then monitor hot water temps. Again, every hour x 4 hours, then twice daily x 3 days, then daily x 7 days then resume the weekly water temp. testing. F. On 2/27/2025, the Plumbing Service arrived at 8:30am to correct hot water temperatures, and this will be completed at 1:15 pm 2/27/2025. On 2/25/2025 the facility conducted an Ad Hoc meeting to include the medical director regarding hot water temp. issues identified, including an action plan. On 2/26/2025 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Hot Water Temps. and reviewed a plan to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _______2/27/2025_________ Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record review from 02/27/2025 at 1:45 PM to 02/27/20254 at 5:11 PM as follows: During an Observation on 2/25/2025 at 7:30 PM all resident sinks had water turned off and shower rooms had been locked with signs placed on the doors that stated see nurse before entering. During an observation on 2/25/2025 at 7:30 PM all shower rooms had been secured and signs on the doors stated, See nurse before entering. During an observation on 02/27/2025 at 2:32 PM staff were alerted with signs being placed and observed on all locked shower doors on East and [NAME] Halls. During an interview on 2/27/2025 at 2:49 PM, on the day shift, CNA E stated she was in-serviced over what to do if she felt the water was too hot. She stated if she was giving a resident a shower, she would check the water temperature first before letting the resident under it. She stated if it was too hot, she would not have the resident in the shower, and she would let the ADMN and maintenance know. CNA E stated she would do the same with the resident sinks. During an interview on 02/27/2025 at 2:59 PM, on the day shift, CNA F stated he would turn the water off if it were too hot, notify the nurse, then he would notify the ADMN. During an interview on 02/27/2025 at 3:02 PM, on the day shift, CNA G stated if she felt the water was too hot or if the resident stated to her it was too hot she would immediately turn it off, assess the resident if needed, then report to the charge nurse, the ADMN and maintenance. During an interview on 02/27/2025 at 3:10 PM, on the day shift, the ADON stated she was in-serviced over what to do if the hot water was too hot in the resident showers and sinks. She stated she should turn off the hot water immediately, and notify the ADMN, maintenance, and the nurse on duty. During an interview on 02/27/2025 at 3:12 PM, on the day shift, LVN D stated she was in-serviced over what to do if the hot water temperature was too hot. She stated if she felt it was too hot, she would immediately notify the charge nurse, the ADMN, and the maintenance man. After turning the hot water off, she would also assess the resident and notify other staff members. During a phone interview on 02/27/2025 at 3:32 PM, CNA H from the night shift, stated she was informed on 02/25/2025 on her shift about the hot water being turned off and to not do any showers until further notice. CNA H stated she had been in-serviced on if the water in the showers or resident sinks felt too hot to turn it off. She stated she would then tell the charge nurse, the ADMN, the DON and maintenance. CNA H stated she was told if she saw there were signs on the shower doors to see the charge nurse. During a phone interview on 02/27/2025 at 3:35 PM, CNA I from the night shift, stated she was told the night of 02/26/2025 about the hot water being turned off and to not give the residents showers until further notice. CNA I stated she had been in-serviced on, if giving showers and she felt the hot water was too hot, to turn it off and tell the charge nurse, the DON, the Administrator, and maintenance. During a phone interview on 02/27/2025 at 4:09 PM, RN A who alternated between day and night shifts, stated she had received in-services on if the water in the showers were too hot, she should turn it off, perform a head-to-toe assessment on the resident, notify the DON, the ADMN, and maintenance. RN A stated there were signs placed on the shower door that said, do not enter see nurse. During an interview on 02/27/2025 at 4:52 PM, LVN J stated she was told the previous night about the water had been turned off and not to give the residents showers. LVN J stated she was in-serviced on if the water in the showers or resident sinks were too hot, to turn off the water, then she would be responsible for doing a skin assessment on that resident if needed. LVN J stated she would then call the ADMN and maintenance to inform them the water was too hot. During an interview on 02/27/2025 at 2:52 PM, the MM stated he was in-serviced on hot water, and what to do if he found it to be above 110 F. He stated he would immediately turn it off and proceed to call the ADMN as well as corporate, and the plumbing company. During an interview on 02/27/2025 at 2:44 PM the DM stated she was in-serviced on the hot water. If water was steaming to not place hands under water, especially residents, and if noticed that it was steaming, she would turn the water off and notify the nurse in charge, and the MM of the situation. The DM stated she would also update the ADMN as well. The water should be no higher than 110 F. During an interview on 02/27/2025 at 2:46 PM, the DA stated he was also in-serviced on the hot water and to turn it off if he found it to be too hot for the residents. He stated he was told to notify upper management if the hot water was higher than 110 F . Record review of the facility provided staff in-services revealed staff were provided an in-service on 02/25/2025, 02/26/2025, and 02/27/2025 related to water temperatures being over 110 F and showers being locked. Record review of receipt from Plumber 1 revealed services were rendered on 02/26/2025 and 2/27/2025. Record review of the facility provided temperature logs for 02/26/2025 at 7:00 PM, revealed temperatures were taken at 7:00 PM and were below 110 F. Record review revealed the MM was provided in-services on 02/26/2025 and 02/27/2025. Record review of facility provided water temperature logs revealed the temperatures were checked every 4 hours starting on 02/26/2025 at 7:30 PM until 2/27/2025 at 6:30 AM. Record review of the receipt from Plumber 2 revealed services were rendered on 02/27/2025. Record review of facility provided skin assessments revealed on 02/26/2025 Resident #60, Resident #168, Resident #167, Resident #14, Resident #37, Resident #50, and Resident #38 received a head-to-toe assessment, and no issues were noted. ? An Immediate Jeopardy was identified on 02/26/2025. While the Immediate Jeopardy was removed on 02/27/2025, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm and a scope of pattern, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN, the DON, and the RRN were informed of the Immediate Jeopardy was removed on 02/27/2025 at 5:11 PM. 44728

Based on interviews and record review the facility failed the ensure physician visits were conducted within 2-7 days of admission, once every 30 calendar days for the first 90 calendar days for 3 of 24 residents (Resident #22, Resident #23, and Resident #50) who were review for physician visits. 1. The facility failed to have Resident #22 seen by a physician within 2-7 days of readmission (07/31/2024), once every 30 calendar days for the first 90 calendar days. 2. The facility failed to have Resident #23 seen by a physician within 2-7 days of readmission (11/28/2024), once every 30 calendar days for the first 90 calendar days. 3. The facility failed to have Resident #50 seen by physician within 2-7 days of readmission (07/31/2024), once every 30 calendar days for the first 90 calendar days. This deficient practice could lead to a decline in health status or untreated conditions. Findings included: Resident #22 Review of Resident #22's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admitted [DATE]. Resident #22's medical diagnoses included Alzheimer's disease, COPD, type 2 diabetes, major depressive disorder with psychotic symptoms, generalized anxiety disorder, muscle weakness, difficulty walking, and contact with and (suspected) exposure to other viral communicable diseases. Review of Resident #22's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 13 (cognitively intact). Review of Resident #22's Comprehensive Care Plan initiated 08/09/2024 and reviewed/revised 11/11/2024 revealed the following focused areas: *Cognitive Impairment: Resident has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: dementia. An Intervention for the focus on cognitive impairment included Monitor/document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. *Resident #1 has a diagnosis of depression as evidenced by tearfulness, change of appetite, and decreased social interaction. An intervention for the focus on her depression included Administer medications as ordered. Monitor/document for side effects and effectiveness. Arrange for psych consult, follow up as indicated. Discuss with the resident/family/caregivers any concerns, fears, issues regarding health or other subjects. Monitor/record/report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment, or safety awareness. *Diabetes: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars and abnormal lab results. An Intervention for the focus on her diabetes included: Administer diabetic medications as ordered by the physician. Monitor for adverse reactions and report abnormals as detected. Provide therapeutic diet as ordered. Monitor blood Sugar as ordered by physician. Administer sliding scale insulin if ordered. For any blood sugars not within the acceptable parameters as dictated by the physician, document and notify the physician. Monitor for signs and symptoms of hypoglycemia such as: diaphoresis, dizziness, headache, confusion, hunger, irritability, pallor, tachycardia, slurred speech, tremor, lack of coordination, and staggering gait. Document and report to physician as needed. Monitor for signs and symptoms of hyperglycemia such as: Reduced appetite, increased thirst, urinary frequency, weight loss, fatigue, nausea, vomiting, dry skin, muscle cramps, Kussmaul breathing (deep and labored breathing), acetone breath (smells fruity), stupor, and coma. Document and report to the physician as needed. Review of Resident #22's Physician/NP/PA Progress Note reviewed on 02/28/2025 revealed: Created By NP and Revised By NP revealed there was no physician visits noted. Resident #23 Review of Resident #23's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admitted [DATE]. Resident #23's medical diagnoses included muscle weakness, insomnia, edema (swelling), urinary tract infection, dependent on renal dialysis, mild dementia, diabetes, and lack of coordination. Review of Resident #23's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 13 (cognitively intact). Review of Resident #23's Comprehensive Care Plan initiated 04/18/2018 and reviewed/revised12/27/2023 revealed the following focused areas: *Falls: Resident has the potential for falls related to cognitive impairment, antihypertensive drug use, Psychoactive drug use, Gait/balance problems, Fall Risk Score >10 and night terrors. An Intervention for the focus on falls included using an Alarm when in bed due to poor safety awareness, *Fall Risk Screening upon admission and quarterly to identify risk factors, An intervention was to Keep bed in lowest position when not providing care. Review of Resident #23's Physician/NP/PA Progress Note reviewed on 02/28/2025 revealed: Created By NP, and Revised By NP revealed there was no physician visits noted. Resident #50 Review of Resident #50's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admitted [DATE]. Resident #50's medical diagnoses included: need for assistance with personal care, Cognitive communication deficit, dementia, psychotic disturbance, mood disturbance and anxiety disorder. Review of Resident #50's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #50's Comprehensive Care Plan initiated 09/09/2024 and revised on 10/08/2024 revealed the following focused areas: *Behavioral Problem: Resident has a behavior problem as evidenced by agitation and yelling at others. An intervention for the focus on behavioral problems included using an Intervene as necessary to protect the rights and safety of others, remove resident to an alternate location when needed to protect the rights and safety of others by offering to sit outside or activity in room. *Wandering/exit Seeking: Resident wanders related to cognitive impairment and is at risk for injury related to: Dementia. An intervention for the focus on wandering/exit seeking included: Attempt to determine any pattern or cause of wandering, reassure resident when distressed over placement, mark room door with a familiar object, to remember room location as indicated. *Secured Unit: Resident resides in a secured unit related to cognitive impairment/elopement risk secondary to Dementia Date initiated 06/27/2024, with a revision date 10/08/2024. An intervention for the focus on behavioral problems included, Monitor for adjustment to a new environment. Place resident within the facility according to their cognitive and functional abilities. Review of Resident #50's Physician/NP/PA Progress Note reviewed on 02/28/2025 revealed: Created By NP and Revised By NP revealed there was no physician visits noted . During an interview on 02/27/2025 at 8:44 AM, the RNC stated the facility could not provide any further physician visits due to we don't have them, they are not there. She stated the Medical Records staff along with the DON monitored resident physician visits. The RNC stated the failure to do so was missing personnel which had changed 5 times in the past year. She stated her expectations were for the NP to visit residents every 60 days and the MD every 30 days for the 1st 30 days of admission. She stated there could have been a negative impact on residents and potentially not receive the medical care they needed. During an interview on 02/27/2025 at 9:00 PM, the DON stated the procedures for physician visits were for them to see residents at least every 120 days. She stated she felt the facility would be getting a new medical director. The DON stated Medical Records, and the MDS nurse monitored physician visits. She stated the MDS had only been employed at the facility for about 6 weeks, and they were using a sister facility as a backup for visits. She stated since the MDS nurse had been hired they had not gone over the physician visits. The DON stated the possible negative impact to the residents were that the NP could have possibly not caught something that needed more knowledge. She stated the failure occurred with the change of staff. The DON stated her expectations were for the Doctor to see residents as per protocol. Record review of the facility policy Physician Visits with date implemented of 10/24/2022 revealed: Policy it is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. Policy Explanation and Compliance Guidelines: 1. The Medical Records staff/designee should: a. Track due dates of physician visits. b. Gather medical records and other documents for review by the physician during the visit. c. Provide records such as weight and vital sign records, accident reports, risk assessments, etc. for physician review. d. Remind the physician to date and sign all orders and write a progress note. e. Review the medical record for completeness, prior to the physician leaving the facility. f. Inform the Director of Nursing when a physician visit does not occur within the required timeframes. (Note: A physician visit is considered timely if it occurs no later than 10 days after the date the visit was required.) 2. The Physician should: a. New/readmission are preferably seen within 2 to 7 days of admission to the facility. b. See resident within 30 days of initial admission to the facility. c. The resident must be seen at least once every 30 calendar days for the first 90 days after admission . .i. At the option of the physician, required visits in SNF 's, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by state law and under the supervision of the physician.

Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings included: Review of the AD's employee file revealed the AD took the position on January 27, 2025, and had no evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. During an interview on 02/25/2025 at 4:00 PM the AD stated she was new to the facility, and she had started on 01/25/2025. The AD stated she had not received her AD certification at this time and was working on her AD certification . During an interview on 02/27/2025 at 11:53 AM the ADMN stated his expectation was to have a licensed Activity Director. The current AD was not certified, and she came from a sister facility where she was as an assistant AD. The ADMN stated he was responsible to ensure the AD was certified. The ADMN stated he did not feel there was an effect on residents, because the AD had previous experience and had a good rapport with residents. The ADMN stated what led to failure was out of the candidates she was the best candidate and none of the applicants were certified. Review of the facility's job description for the Activity Director revealed, qualifications: a degree and license and recreation therapy from an accredited school. Or a high school diploma or equivalency certificate with two years of experience in social or recreational programs within the last five years, one year which was full time and a patient activities program at a healthcare setting. Successful completion on a state approved and certified course of instruction and patient activities. An individual who is exempt from completion for the state approved course is: a person employed full time in the activity's director position since January 1st, 1976 or a person who successfully completed a minimum of 36 hours activities director course prior to August 31st1978, which is sponsored by an accredited educational institution our professional group or association.

Based on interviews and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 surety bonds reviewed. The facility failed to ensure that the facility's $30,000.00 surety bond was enough to cover the $32,6635 total residents' trust fund account balance. This deficient practice could affect all residents who deposited personal funds with the facility, and place residents at-risk of their personal funds not being assured. The findings included: Record review on 02/27/2025 of the facility's Bond Execution Report revealed bond amount $30,000 processed date 06/04/2024. Record review 02/27/2025 of facility's Bank Account Statistics Report with date range 10/01/2024 to 12/31/2024 revealed average balance $32,266.35. During an interview on 02/27/2025 at 3:10 PM the ADM stated he did not know why the surety bond amount was less than the average balance reported. The ADM stated it could be to the transition to Deluxe Health Care now being a consultant. The ADM stated the amount of the surety bond could be incorrect due to an increase in the census. The ADM stated he did not feel this affected residents in any way . Record review of the facility's policy titled: Resident Trust Fund Policies last revision date of 02/2006. The trust fund account must be identified as Trustee, (name of facility), Resident's Trust Fund Account. The Trust Fund Account must be an interest-bearing account that is separate from any of the facility's other accounts. Surety Bond The facility is required to carry a surety bond on the cumulative total of all residents' trust fund balances. The required amount should be calculated using the Surety Amount Calc form. The Surety bond must equal the average monthly balance of all the facilities resident's trust fund accounts for the 12-month period preceding the bond issuance or renewal dates. Resident Trust Fund accounts are specific only to the single facility purchasing a resident trust fund surety bond

Based on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. Hair net was not used for the DA, while he entered the kitchen. 2. Hand hygiene was not performed by CNA-C and the AD while passing trays in the hallway. These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on 02/24/2025 beginning at 10:30 AM the facility kitchen revealed: 1. The DA entered through the back entrance door, walked through the kitchen, and out the front door of the kitchen with no beard cover on. 2. Hand hygiene was not used during the passing of trays in the hallways for CNA-C and the AD. During an interview on 2/24/2025 at 12:05 PM CNA-C on the MCU failed to perform hand hygiene when serving and setting up food between residents. CNA-C was also observed leaving the MCU to go to kitchen to get silverware for a resident. When she returned, she gave the residents her silverware and proceeded to get another tray without performing hand hygiene. CNA-C stated she should have performed hand hygiene and did not have a reason as to why she did not . During an interview on 02/24/2025 at 3:23 PM, the DM stated the DA should have stopped at the back door prior to entering the kitchen and placed a beard restraint on. She stated the DM monitored her dietary staff for hygiene practices. The DM stated once the trays arrived on the hallways, the DON should have been responsible for her staff and their trainings. She stated the negative impact for residents could have been cross contamination which could have allowed residents to have infections. The DM stated the failure occurred with staff not having followed IC practices as they were trained. She stated her expectations for the passing of trays, were the staff should have used hand hygiene between passing trays to each resident. During an interview on 02/24/2025 at 3:36 PM, the DA stated he should have placed a beard restraint on prior to having walked through the kitchen. He stated he had not done so, due to being in a hurry. He stated it could have caused hair in food and/or cross contamination. During an interview on 02/25/2025 at 4:00 PM the Activities Director stated she was new to the facility and started January 27th of this year. She stated she was told after passing trays to residents that she needed to perform hand hygiene between residents. She stated she had not taken her IC trainings concerning hand hygiene. She stated in not doing so, she could have contaminated residents if sick or possibly have caused cross contamination between residents. The AD stated she was working on her food handler's certification and had not received it at that time of the interview. During an interview on 02/27/2025 at 8:50 AM, the DON stated that the staff that passed trays should hand sanitize their hands between each resident, and that staff should have worn hair restraints while inside the kitchen. She stated she was responsible for monitoring staff and hygiene once the food went to the floor and passing out the trays to residents. The DON stated the negative impact to residents in not doing so would be hair in their food, infection control, and contamination of the resident food. She stated the failure occurred with the staff getting in a hurry. The DON stated her expectations were for staff to slow down and do what they were taught. Record Review of the facility's policy Food Safety and Sanitation Plan with a review date 07/22/2021 revealed: Policy: It is the policy of this facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur. The Hazard Analysis Critical Control Point (HACCP) Plan is an example of such a program. Fundamental Information: HACCP, is a food safety plan designed to prevent the outbreak of foodborne illness. It ensures safe food handling practices from food procurement through food service. While all steps in the handling of food are important, specific steps have been identified as critical in preventing food borne illness. HACCP requires food handling at each critical point. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices. Corrective actions are built in to the system for implementation when improper procedures are discovered through monitoring. HACCP is not an exact science, but rather a tool for creating a better understanding and awareness of the potential for foodborne bacterial contamination of food and how to best control this in a food service operation. Nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices present a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling. Review of the FDA Food Code 2022 FDA Food Code 2022: Full Document accessed 02/27/2025 revealed: 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints. (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions

Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #168) of 10 residents reviewed for care plan completion. The facility failed to complete Resident #168's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Review of Resident #168's Face Sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #168's medical diagnoses included COPD (Chronic Obstructive Pulmonary Disease), alcohol dependence, nicotine dependence chronic pain, respiratory failure, and homelessness. Review of Resident #168's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 15 (cognitively intact). Review of Resident #168's baseline care plan revealed a completion date of 02/25/2025. During an interview on 02/26/2025 at 6:52 PM the DON stated her expectation was that baseline care plans were to be completed within 48 hours of admission. The DON stated it was her responsibility to complete and monitor the completion of the baseline care plans. The DON stated the residents could have been affected by the baseline care plan not being complete timely by their care needs not being met. The DON stated what led to the failure was Resident #168 was admitted on Friday evening and she had missed completing the baseline care plan within the 48 hours. Review of the facility policy titled, Baseline Care Plans dated 11/8/2026 revealed, Baseline care plans are developed and implemented within 48 hours of a resident new admission.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 5 medication carts reviewed for storage. The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. The findings included: During an observation on 02/25/25 at 5:05 PM medication cart #1 was sitting against the wall with the drawers facing outwards unattended and unlocked. The button that locked on the medication cart was not pushed in and the drawer could open when pulled. There were no staff seen on the halls. RN A came walking up the hall. She stated the medication cart should not have been left unlocked and unattended. RN A stated the nurse responsible for the cart was RN B. RN A stated RN B was in the dining room assisting residents with their meals. RN A locked the medication cart #1 . During an interview on 02/26/2025 at 06:52 PM the DON stated her expectation was that the medication carts should have been locked. The nurse assigned to the medication cart was responsible for locking and monitoring the medication cart while doing rounds at the facility. The possible effect on residents was they could take the wrong medication, and this could make them sick or cause death. The DON stated the failure was due to the nurse got distracted, walked away, and forgot to lock the medication cart. During an interview on 02/27/2025 at 04:09 PM RN B stated the medications carts should be locked when not in use. RN B stated a resident could take a medication that was not prescribed for them and have a reaction or even cause death. RN B stated she just got busy and forgot to lock the medication cart. RN B stated types of medications on the cart were cardiac medications, blood pressure medications, over the counter medications, stool softeners, vitamins, eye drops, and inhalers but no insulin. RN B stated she had been trained to keep the medication carts locked when not in use. Review of the facility's policy titled: Medication Storage date revised 01/02/2024 revealed: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated, and labeled according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation oof the person administering medications or locked in the medication storage area/cart 44722

Based on interviews, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 10 residents (Resident #50) reviewed for resident rights. The facility failed to obtain a signed consent for admission to reside onto the facility's Memory Care Unit. This failure could affect residents who were placed and received care placed on the Memory Care Unit without informed consent. Findings included: Review of Resident #50's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admitted [DATE]. Resident #50's medical diagnoses included: need for assistance with personal care, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Review of Resident #50's annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #50's Comprehensive Care Plan initiated 09/09/2024 and revised on 10/08/2024 revealed the following focused areas: *Behavioral Problem: Resident has a behavior problem as evidenced by agitation and yelling at others. An Intervention for the focus on behavioral problems included using an Intervene as necessary to protect the rights and safety of others, remove resident to an alternate location when needed to protect the rights and safety of others by offering to sit outside or activity in room. *Wandering/exit Seeking: Resident wanders related to cognitive impairment and is at risk for injury related to: Dementia. An Intervention for the focus on wandering/exit seeking included: Attempt to determine any pattern or cause of wandering, reassure resident when distressed over placement, mark room door with a familiar object, to remember room location as indicated. *Secured Unit: Resident resides in a secured unit related to cognitive impairment/elopement risk secondary to Dementia Date initiated 06/27/2024, with a revision date 10/08/2024. An Intervention for the focus on behavioral problems included, Monitor for adjustment to a new environment. Place resident within the facility according to their cognitive and functional abilities. Review of Resident #50's physician orders reviewed on 02/21/2025 revealed: May admit to a secured unit for specialized dementia care, dated 9/4/2024. Review of Resident #50's consents revealed there was no signed consent by resident or resident Representative, in her EMR, to be admitted on to the facility MCU. During an interview on 02/27/2025 at 9:35 AM, HR stated there was no documentation of a consent for Resident #50 for the MCU. She stated all MCU residents should have had a consent signed and documented . During an interview on 02/27/2025 at 9:40 AM, the DON stated Resident #50 had no consent in her paper file nor in her electronic charting. She stated it was protocol for all residents on the MCU to have a signed consent on file prior to being admitted to the unit. The DON stated she would get a consent from Resident #50's daughter immediately which would be a verbal. She stated that would be the only way to retrieve the consent until her was in town for a visit. She stated Medical Records had the consents signed upon admission, but that position had not been consistent with being filled. She stated, the failure occurred with personnel and not having checked on the paperwork for proper completion. The DON stated the resident impact for not having a consent would have possibly been that residents being placed in an area that was locked and unable to have the same right as other residents. She stated her expectation was for all paperwork to be completed in a timely manner where and when needed. During an interview on 2/27/2025 at 10:16 AM the RNC stated, it was the Admission Coordinators responsibility to have all resident paperwork completed prior to being placed on the MCU but there was not one available. The RNC stated it was then MR's responsibility, but that position had recently been open as well. She then stated it was ultimately the Administrator who should have overseen the process of making sure the consents were signed. The RNC stated the negative impact for Resident #50, could have been potentially a Resident Rights issue. The RNC stated the failure occurred with facility personnel changes with her expectation was for all residents to have consents prior to being admitted to the MCU. During an interview on 02/27/2025 at 10:39 AM the ADMN stated the protocol for being admitted to the MCU was to have a consent signed prior to being admitted into the MCU. He stated the SW and nursing staff as well as the ADMN were the staff who monitored. The ADMN stated he did not feel there was a negative impact for this particular one, she was back there at the request of her family, and she did not mind being back there. He stated the protocol was not followed, but the family wanted her there. The ADMN stated the failure occurred on admission, with his expectation for the facility to have reached out to the Resident Representative for the consent to be signed and available. Record Review of the facility policy Admission criteria for Secured Continuous Care Unit, dated with origination date of 01/10 and Review date of 5/16/24, revealed Policy- an admission to the Secured Continuous Care Unit will be performed in a uniform manner. Residents eligible for admission to an SCCU will have a diagnosis of Alzheimer's, Dementia, or related disorders. Residents with cognitive impairment who may have unsafe wandering or exit seeking may meet eligibility for admission to an SCCU. The need for admission must be documented by the attending Physician Assessment Tools for Admission to SCCU- .6. Secure Continuous Care Unit Acknowledgement Form.

Based on observations and interviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff sanitized the thermometer while taking temperature of food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 01/08/2024 beginning at 11:30 AM Cook C removed the thermometer from the mashed potatoes and placed it in the Beef and Cabbage and then in the gravy. Cook C failed to sanitize the thermometer between taking the temperature of each food. During an interview on 01/09/24 at 10:45 AM the DM stated her expectation when taking temperatures of food was the thermometer should have been cleaned with an alcohol swab before placed in a food and after removed from item. The DM stated Cook C should have not been dipped into water between each use. The DM stated the cooks were responsible to take the temperatures, but she was responsible to monitor. The DM stated not sanitizing the thermometer could have caused the residents to receive food that was exposed to cross contamination, and they could have gotten sick. The DM did not have an explanation to what led to failure. During an interview on 01/10/24 at 02:24 PM the Dietician stated Cook C should have sanitized the thermometer before she placed the thermometer into food. The Dietician stated not properly sanitizing the thermometer could have caused cross contamination. During an interview on 01/10/24 at 3:31 PM the ADMN stated his expectation was the thermometer should have been sanitized before each use. The ADMN stated not sanitizing the thermometer could have led to cross contamination. The ADMN stated staff being in routine and nerves could have led to the failure. During the exit conference on 01/10/2024 at 7:30PM the ADMN and RNC stated they did not have any other polices to provide.

Based on interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for infection control procedures for 3 of 5 (#4, #17, and #44) residents reviewed for infection control. The facility failed to follow their Infection Control policy regarding CDC guidelines of performing the Flu test in conjunction with their COVID-19 testing. this failure could place residents at risk of the spread of infections. Findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old female originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included: COVID-19, Streptococcus Pneumoniae (a bacteria commonly inhabited in the respiratory tract). Record review of Resident #4's physician orders dated 01/07/2024 revealed: Perform COVID-19 antigen test with a start date of 11/19/2023. Record review of Resident #4's quarterly MDS dated [DATE] revealed: BIMS score of 01 (meaning severely impaired). Record review of Resident #4's care plan dated 10/04/2023 revealed: Resident has diagnoses of a viral respiratory infection (COVID 19, RSV, Influenza) and is a risk for: Respiratory complications (including impaired oxygen exchange). Resident #17 Record review of Resident #17's electronic face sheet dated 01/10/2024 revealed resident was a [AGE] year-old female admitted on [DATE] with diagnoses that included: COVID-19 and chronic obstructive pulmonary disease (lung disease interfering with breathing) and shortness of breath. Record review of Resident #17's physician orders dated 01/10/2024 revealed: Perform Covid-19 antigen test with a start date of 09/04/2023. Record review of Resident #17's quarterly MDS dated [DATE] revealed: BIMS score of 07 (meaning severely impaired). Record review of Resident #17's care plan dated 01/05/2024 revealed: Resident has dx of a viral respiratory infection (COVID 19) and is a risk for: Respiratory complications (including impaired oxygen exchange) Resident #44 Record review of Resident #44's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old male admitted on [DATE] with diagnoses that included: COVID-19, ALZ (disease of the brain affecting memory and function), and respiratory disorder. Record review of Resident #44's physician orders dated 01/10/2024 revealed: Perform Covid-19 antigen test dated 09/07/2023, and Covid-19 antigen test dated 11/19/2023. Record review of Resident #44's quarterly MDS dated [DATE] revealed: BIMS score of 99 (meaning severely impaired). Record review of Resident #44's care plan dated 10/03/2023 revealed: Resident has dx of a viral respiratory infection (COVID 19) and is a risk for: Respiratory complications (including impaired oxygen exchange). An interview on 01/09/2024 at 9:10 AM the RNC stated one resident was tested this day due to showing signs and symptoms. She stated the facility staff followed CDC guidelines which was stated in their policy. The RNC stated they had not tested residents or staff for the flu while testing for COVID. An interview on 01/09/2024 at 04:24 PM the ADMN stated he had not reviewed the CDC guidelines recently, but the DON and ADON-B most likely had. He stated he did not know if the flu test had been performed on the residents when they performed the COVID test and had not realized those two tests needed to coincide with each other. In an interview on 01/10/24 10:20 AM the RNC stated she was not aware the flu and covid test needed to coincide or performed at the same time. She stated the ADON-B and the DON, if in the facility had tested the residents and staff, but if they were unavailable to do so, she herself (RNC) helped out and monitored Infection Control. The RNC stated they had a policy committee that met every 2 months to review the updated CDC guidelines. She stated she felt the negative impact to the residents would have possibly having/getting the flu or spreading the current illness. She stated she was not sure what she would do differently. The RNC stated the failure was not following CDC guidelines and not having performed the flu test to coincide with the COVID test. She stated her expectations were for staff to follow facility policies with CDC guidelines. Record Review of Facility policy COVID-19 Visitation dated 10/24/2022, with the revised date of 05/11/2024 revealed: Exceptions will be in accordance with current CDC recommendations, or as directed by state government 4. The core principles of COVID-19 infection prevention will be adhered to and as follows: . .j. The facility will conduct resident and staff testing as current CDC guidance. Record Review of Facility policy Novel Coronavirus Prevention and Response dated 03/07/2022 and last revised date of 05/11/2023 revealed: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus, and for other causes of respiratory illness, such as influenza or other respiratory panels. Record CDC Guidelines title Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating accessed on 11/14/2023 at https://www.cdc.gov/flu/professionals/diagnosis/testing-management-considerations-nursinghomes.htm revealed: 2. Test any resident with symptoms of COVID-19 or influenza for both viruses.

48883 Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 3 (Resident #103, Resident #104, and Resident #202) of 8 residents reviewed for care plan completion. The facility failed to complete Resident #103's, Resident #104, and Resident #202 baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Resident #103 Record review of Resident #103's electronic face sheet dated 01/10/2024 revealed resident was a [AGE] year-old female admitted on [DATE], a code status of full code, with diagnoses that included: Pneumonia (lung infection), End stage renal disease (advanced kidney disease), and dependence on renal dialysis (dialysis to remove wastes that kidneys are no longer able to remove). Record review of Resident #103's baseline care plan started on 12/28/2023 revealed RN-DON signed date of 01/04/2024. Resident #104 Record review of Resident #104's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old male admitted on [DATE], a code status of full code, with diagnoses that included: alcohol dependence, major depressive disorder (depression), Alzheimer's Disease (disease of the brain affecting memory and function), muscle weakness, lack of coordination, history of falling, needing assistance with personal care, and urinary tract infection. Record review of Resident #104's baseline care plan started on 12/27/2023 revealed RN-DON signed date of 01/01/2024. Resident #202 Record review of Resident #202's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old female admitted on [DATE], a code status of full code, with diagnoses that included: COVID-19 (disease caused by a virus), presence of cardiac pacemaker, muscle weakness, limitation of activities due to disability, and hypertension (high blood pressure). Record review of Resident #202's baseline care plan started on 12/28/2023 revealed RN-DON signed date of 01/01/2024. During an interview on 01/10/2024 at 1:48 p.m., the RNC stated the DON was responsible for completing baseline care plan. The RNC stated that the DON was not working at the time of the interview. The RNC stated her expectation was for baseline care plans to be completed after Social Services, Nursing and Dietary completed their sections. She stated that baseline care plans are completed when RN signed baseline care plan. The RNC stated that she felt that failure to complete in required time frame occurred due to facility having to perform extra tasks related to COVID requirements. During an interview on 01/10/2024 at 2:34 p.m., the RNC stated that she was in the process of performing an in-service on baseline care plans. She stated that this failure could lead to resident's not getting the care that they needed. Record review of facility policy titled; Baseline Care Plans dated 11/08/2016 and revised on 07/16/2023 revealed: Baseline care plans are developed and implemented within 48 hours of a resident new admission. The baseline care plans include measurable objectives to address the resident's immediate medical, clinical, functional, mental, and psychosocial person-centered needs. Baseline care plans are developed by Registered Nurses and other healthcare team members. The LVNs and other healthcare team members execute baseline care plans. Overall care coordination of the resident is evaluated by the DON/designee.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #3) of 6 residents reviewed for assistance with transfers using the mechanical lift as evidenced by: Resident #3, who required 2-person assist for transfers with a Hoyer Lift slipped out of Hoyer Lift sling. On 03/10/19 CNA I failed to ensure that Resident #3 was positioned properly in the Hoyer Lift Sling before she attempted to transfer Resident #3 from her bed to the wheelchair without the assistance of a second staff member. While the Hoyer Lift sling was being raised from the bed, Resident #3 slid out of the sling to the floor resulting in fractures of the tibia and fibula. This failure resulted in actual harm to Resident #3 on 03/10/19. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents at risk of accidents which could lead to a fall resulting in injury to residents and reduce their quality of life. Findings included: Resident #3 Review of Resident undated Face Sheet, for Resident #3 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 was unable to participate in the Brief Interview for Mental Status (BIMS) indicating she had severe cognitive impairment. MDS indicated her speech was unclear, she was rarely able to make herself understood, and she was able to understand others at times. MDS indicated she was totally dependent on two people and a Hoyer Lift for transfers. She required extensive assistance of two people for bed mobility, toileting, and personal hygiene. Resident #3 was dependent on one person for bathing and dressing. MDS also indicated Resident #3 was always incontinent of urine and bowel. Review of Resident #3's care plan dated 06/25/18 and reviewed on 02/20/19, to continue plan of care, indicated Resident #3 was at risk for falls related to right sided [MEDICAL CONDITION], Hoyer lift transfer, and cognitive impairment. The Long Term Goals was listed as, I will be free from major injury from fall. The Approach's were listed as: - Assess for medications which may be contributing factor - Encourage to use call light as needed and assist with ADL's as needed. Place call light within easy reach of me while in room. - Monitor for 72 hours post fall for any injuries that could be fall related. - Neuro checks for any unwitnessed fall when I cannot tell you that I hit my head or not. - Notify physician of falls. - Report changes in endurance, positioning, and transfers to PT/OT Review of the Facility Incident/Accident Investigation Worksheet dated 03/10/19 revealed CNA I was getting Resident #3 up when resident straightened her leg out and slipped out of the sling and fell on to the floor. The Physician and family were notified. Record review of the SBAR Communication Form dated 03/10/19 and written by LVN G revealed the following: The change in condition started on 03/10/19. Her primary diagnose were cerebral infarction unspecified and other [MEDICAL CONDITION]. Her vital signs were B/P 152/86, Pulse 70, Respirations 18, her temperature was 97.8?. It was documented there were no changes in Resident #3's mental status, functional status, behavioral evaluation, respiratory evaluation, cardiovascular evaluation, pain and neurological evaluation. There was no bruising or swelling or complaints of pain. Observation on 03/26/19 at 2:45 p.m. Resident #3 was sitting up in her wheelchair with her right lower extremity elevated and an immobilizer was noted to that extremity. Observation on 4/4/19 at 3:50 p.m. Resident #3 was sitting in her wheelchair with her right leg elevated. Immobilizer was in place. She was sitting in the lobby with her husband, she was clean well groomed, she was friendly and approachable. Observation and interview on 04/09/19 at 10:35 a.m. Resident #3 was lying in her bed, she was receiving am care. The CNA said that she was getting her up. Resident #3 nodded her head yes when asked if she was doing ok. She also nodded her head yes when asked if her right leg was hurting. Resident #3 was clean well groomed. Her clothes were clean and in good repair. Her room was clean and uncluttered. She had fluids at bedside and her call light was within reach. Review of Incident/Accident Investigation Witness statement dated 03/10/19, CNA I documented the following. I was transferring resident to her wheelchair when she straightened her leg that's when she slipped out of the sling. As soon as resident fell I called for help. CNA I could not be reached for an interview as her telephone number was no longer in service, per recording. In an interview on 04/02/19 at 8:30 a.m. with DON B she said that she was acting as an interim at the current time. She said that Administrator A and DON B were both terminated because they did not do their due diligence. She said they should have investigated the incident on 03/10/19 involving Resident #3, the fall from the Hoyer Lift. She said the facility/corporate policy is that two people are required at all times to assist in the transfer of a resident while using the Hoyer Lift. In an interview on 04/04/19 at 3:30 p.m. with Resident #3's husband he said the facility called him that morning (03/10/19) to notify him that Resident #3 had slipped out of the Hoyer Lift sling and fell to the floor while the CNA was transferring her from the bed to the wheelchair. He said that the nurse told him that the aide was using the Hoyer lift and she was transferring Resident #3 by herself. He said the nurse told him that Resident #3 was okay that she was not in any pain. He said that it is hard to tell when Resident #3 is any pain because she is not a complainer. He said that she had paralysis in her right leg because of a previous stroke. He said that she just does not feel pain the way most people do. He said that seven (7) days have passed from the time that she fell until the facility got x-rays and transferred her to the hospital. He said that leg had been broken two other times at another local nursing home. He said that day when he saw how swollen her leg was he knew it was broken. He said that he spoke with Administrator A at the time of transfer and he said she told him well accidents happen. He said but this is one accident that should have not happened, it could have been avoided. He said the aide should not have been transferring Resident #3 with a Hoyer lift all by herself. Record Review of Resident #3's Nurses Notes dated 03/10/19 6:00 a.m. - 6:00 p.m. shift and written by LVN F indicated no complaints of pain, status [REDACTED]. neuro checks within normal limits. Will monitor. Record Review of Resident #3's Nurses Notes dated 03/15/19 at 8:40 p.m., and written by LVN G revealed the following: Resident #3's husband stated his wife was in pain and that her right leg is swollen and requesting x-ray. At 8:45 p.m. spoke with DON regarding situation and status [REDACTED]. Spoke with husband explained the situation and asked him if he wanted to send Resident #3 to the emergency room (ER). He stated he doesn't want her up in the wheelchair early am. Husband going to call in am to check on her and decide if he wants to send her to the ER. Record Review of Nurses notes dated 03/15/19 revealed late entry 8:45 p.m. and written by LVN G revealed the following: administered PRN Tylenol 325 mg tabs per PRN order. Tolerated well, facial grimacing noted. Late entry 4:00 a.m., CNA reported resident complain of pain during turning, facial grimacing noted. When asked if she was in pain, nodded head yes. Administered PRN Tylenol 325 mg PO per MD orders . Record Review of Nurses Notes dated 03/16/19 late entry for 4:00 a.m. and written by LVN H. CNA reported resident complained of pain during turning, facial grimacing, nodded head when asked if she was in pain. Administered PRN Tylenol 325 mg PO per MD order Resident only complains of pain with movement to right leg. Right leg [MEDICAL CONDITION] 3+, shiny and warm to touch. Bruising noted below right knee down the ankle. Resident was not gotten up this am per husband request. Have reported to on-coming nurse regarding husband's requests and possible sending resident to the ER. Review of Resident #3's Physician order [REDACTED]. Review of Resident #3's Portable x-ray results taken on 03/16/19 at 9:57 a.m. revealed there were three views taken of Resident #3's right leg; Impression: Fractures of the tibia and fibula. X-ray; three views of the right knee; Impression: Acute fractures of the tibia and fibular neck. X-ray of right foot (3 or more views) Impression: Osteopenia. Repeat imaging in 7-10 days would be recommended if pain persists given the underlying osteopenia. Record Review of the Nurses Notes dated 03/16/19 at 2:00 p.m. and written by RN C revealed the following: Resident #3 was noted to have a swollen right leg. That is tender to touch, warm to feel, and expressing excruciating pain with movement. Orders were received to carry out x-ray from the hip down. X-ray results were received and Resident #3 was noted to have some fractures to the tib/fib and femur . Further orders received to transfer. Resident #3 to the local hospital to the Emergency Department (ED) for further evaluation and care. Family aware of finding. In an interview on 04/02/19 at 4:45 p.m. with the Clinical Service Director (CSD) regarding the incident with Resident #3 she said that the incident report (IR) dated 03/16/19 identified that Resident #3 had a fracture of unknown origin. She said it was reported that her leg was swollen and bruised and tender to touch. She said that an x-ray was taken at the facility and it was confirmed that Resident #3 had fractures to the tibia and fibular neck with underlying osteopenia. She said apparently the affected site had been fractured several times before. She said the incident was reported to the state agency as an injury of unknown origin. She said as she was investigating the cause of the fractures she discovered there was an incident involving the Hoyer Lift. She said Resident #3 had an incident earlier in the month, on 03/10/19 where she slipped out of the mechanical lift. She said it was reported to Administrator A and DON A that there was not any injury at that time. She said that Resident #3 had not complained of any pain until that Friday (3/15/19). She said that Resident #3's right leg was swollen. She said that day, Friday 3/15/19, they started doing competency training for transferring with the Hoyer Lift with the nursing staff, which required the staff to do a return demonstration. She said they also began in-servicing all staff on abuse and neglect on that Saturday (3/16/19). She said that it was her understanding that the nurse aide was using the Hoyer Lift by herself when the incident with Resident #3 occurred. She said it was the company policy that two people are required to transfer with the Hoyer Lift. She said that CNA I, the aide that was using the Hoyer Lift by herself when transferring Resident #3 quit and didn't come back. She said that she had made several attempts to speak with CNA I over the phone and at the facility, but she did not hear from her. She said CNA I did work a few nights after the incident, but she is not sure how many. She said she believes that CNA I got scared once it was determined that Resident #3 had a fracture that's when she left a note saying she was not coming back. She said she had not spoken with CNA I at all. She said that the CNA I should have competency training for transferring with the Hoyer Lift upon hire, annually and as needed when something comes up. She said they should do the competency check off before they are allowed to use the Hoyer Lift. She said that they did do competency training with CNA I on 3/14/19. She said that she did review CNA I's personnel file and there was a competency checklist done for transferring with a Hoyer Lift when she was first hired 11/16/17. During observation and interview on 04/04/19 at 12:55 p.m. with CNA E and CNA B as they were transferring a resident to bed from the wheelchair using the Hoyer Lift, CNA E said the only way a resident could slide out of the sling is not having them positioned properly in the sling or not having the sling properly hooked to the lift. CNA B agreed and said that it was most likely that the resident was not positioned in the sling properly. She said that the facility did have one sling that was different than the others. She said you had to crisscross the strap and weave it between the resident's legs. She said since the incident on 03/10/19 with Resident #3 that sling has been pulled off the floor. She said that now all their slings are the same. She said that every resident has their own sling. She said there were six residents that require a Hoyer Lift for transfers. During observation and interview on 04/04/19 at 1:05 p.m. with CNA F and CNA C as they were transferring a resident from the Geri-chair to the bed using the Hoyer Lift, CNA F said that the only way a resident could slip out of a sling is to not have them positioned properly. She said there must always be two people when transferring a person using a Hoyer Lift. CNA C agreed and said that since that accident all the CNAs have been in-serviced and how to use the Hoyer Lift properly. She said they had to do a return demonstration. She said that the facility has plenty of slings now that every resident has their own sling. Observation/interview on 04/04/19 at 1:20 p.m. CNA G and CNA C were transferring a resident from the wheelchair to the bed. CNA G said that there should always be two people using a Hoyer Lift during a transfer. She said there were no exceptions. She said that is not new that every place she has ever worked those are the rules. CNA G said no one can transfer by themselves when using a Hoyer Lift. She said they have plenty of slings now, that everyone has their own sling. She said they always remove the lift slings when they are laying a resident down in bed. She said that she had heard about the incident with Resident #3 and the only way she could have slid out of that sling is for the sling not to be on the lift's hooks properly or the resident was not positioned properly in the sling. She said that the incident was too bad, that Resident #3 should not have had that happen to her, it was completely avoidable. In an interview on 04/04/19 at 10:30 a.m. with the CSD she said that regarding the incident on 03/10/19 with Resident #3, it should have been reported to the state agency. She said the CNA was transferring Resident #3 by herself using a Hoyer Lift, which is against company policy. She said that there should always be two people when using the HL. She said there would never be an exception to that rule unless there was a need of three people, but never one person alone. In an interview on 04/02/19 at 4:15 p.m. with LVN F, she said there should always be two (2) people present in the room when transferring a resident with a HL. She said there were no exceptions. She said since the incident on 3/10/19 with Resident #3 that all the nursing staff have been in-serviced on proper procedure using the HL. She said when Resident #3 slipped out of the HL sling to the floor, CNA I was transferring her by herself from the bed to the wheelchair. She said now there must be two people transferring Resident #3 and there had to be a nurse present as well to ensure Resident #3 was transferred safely and without injury. In an interview on 04/02/19 at 4:40 p.m. with LVN A he said when using a Hoyer Lift there should always be two people. He said that there have not been any incidents regarding the Hoyer Lift on his residents, but he is aware that recently there was an incident where Resident #3 did slide out of the sling to the floor. He said the nursing staff have all been in-serviced on the proper use of Hoyer Lift. In an interview on 04/02/19 at 5:10 p.m. with LVN B he said that he is the one that does the training with the staff for transfers with the Hoyer Lift. He said there should always be two people regardless when the transfer requires the mechanical lift. He said there were different types of lift that works in different ways, which is why you should always use the Manufacturer's recommendations when using the lift. He said some of the lifts require the base to be open, others for the base to be closed, that's why you should be familiar with the lift you are using manufacture's recommendations for use. He said that no matter what lift you use or how you go about using it you should still always have two people when using any mechanical lift, otherwise it could cause a problem. In an interview on 04/09/19 at 3:30 p.m. The Interim Administrator, the Interim DON, and the CSD said their expectation was for staff to Resident #3's Plan of Care utilizing the appropriate interventions for that resident. Nurses were also available to assist nurses' aides in providing care to residents. She said that CNA I should have requested assistance of the other aides and/or nurse to care for Resident #3. She said that Resident #3 required assistance of two staff for her care. Review of CNA I's personnel file revealed she was hired in the Nursing Department on 11/16/17 for the 10:00 p.m. - 6:00 a.m. shift. There were all the necessary background checks completed without issue. There was a signed Job Description for Certified Nursing Assistant. Her NA certification was active without stipulations. There was a signed Hoyer Lift competency check list dated 11/16/17, that indicated CNA I had met the expected goals for competency. (All columns were checked off under the met column). Review of C.N.A. Competency Check List dated 03/14/19 indicated that CNA I had been checked off for Hoyer Lift Transfers. The facility took the following corrective actions prior to surveyor arrival: - Review of in-service dated 03/10/19 at 5:30 a.m. revealed the following: Anytime a lift is used there must be 2 people assisting at all times, no excuses! Thirteen (13) staff members signed the attendance sheet. - Review of in-service dated 03/16/19 (no time documented) revealed the following: Objectives of the in- service: Definitions as defined by CMS section 483.5; 1. Abuse: 2. Adverse event. 3. Exploitation, 6. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 8. Injuries of unknown origin, any of the above allegations need to be reported immediately to the Administrator or DON. Twenty-three (23) employee signatures are present on the attendance sheet. All are considered mandated reporters. Record review of the QAPI dated 03/20/19 revealed the following: Performance Improvement Plan Alleged Concern: Improper Transfer using Mechanical Lift Date of Incident 03/10/19 & 03/16/19 Resident transferred 3/10/19 with Mechanical Lift and slid out of sling during transfer. CNA used improper technique. Resident presented on 3/15/19 with [MEDICAL CONDITION], bruising and pain to right lower extremity Anticipated citation: What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice: - The identified resident returned to the facility on [DATE] - The identified Certified Nurse's Assistant (CNA) no longer works in the facility. How the residents who have the potential to be affected by the alleged deficient practice are identified. - Current residents that are transferred using the mechanical lift have the potential to affected by the alleged deficient practice. - Nurse Manager's assessed current resident for signs/symptoms of unknown injuries. This was completed 03/16/19 How the corrective action will be monitored to ensure the deficient practice will not reoccur. Education: Mechanical Lift Competencies initiated on 03/15/19 - Certified Nurse's Assistants completed Mechanical Lift Competencies. Anyone who has not completed the competency by 03/20/19 will complete by next scheduled shift. - Regional Director of Operations/LNFA re-educated Department Managers on reporting abuse, neglect, and misappropriation of resident property, this education was conducted on 03/18/19 - Staff will be re-educated on Preventing Abuse, Neglect. We will use an employee roster and schedule track and document education compliance. Monitoring: Nurse Managers will randomly observe mechanical lift transfers on a minimum of three (3) residents per week for four (4) weeks than randomly for two (2) additional months. Agency personnel will receive this re-education prior to working scheduled shift. Facility Administrator will be responsible for the overall implementation and validation of this plan. Facility Medical Director was informed of this plan and will be given progress updates. Ad Hoc Quality Assurance Performance Improvement Committee meeting was held on 03/21/19. What quality assurance program will be put into place: - Results of the monitoring will be presented to the Quality Assurance Performance Improvement Committee for further recommendations. - Any discrepancies will be addressed at time of discovery. Allegation of Compliance 03/20/19 Signed by the Medical Director, RVP and CSD on 03/21/19 and signed by the Administrator (interim), the DON (interim) and the Assistant Director of Nursing (ADON) on 03/27/19 at 0800. Review of the Nursing Policy & Procedure dated 03/27/18 for Mechanical Lifts revealed the following: Policy: The facility may employ the use of mechanical lifts to assist with transfers to ensure the safety of patients, residents and staff. Scope: Mechanical lifting equipment includes any permanently mounted or portable/floor-based lifts that may be either powered or manual, used to transfer or move patients/residents. Procedure: 1. Prior to using any mechanical lift device, competence must be documented in the safe and appropriate use of the equipment per policy and manufacturer guidelines, specific to the device. 2. Mechanical lifts may be used for the enhanced safety of patients, residents and staff in situations including but not limited to: A. Lifting from floor. B. Bed to chair transfers. C. Lateral transfers. D. Toileting and bathing. E. Repositioning. F. Sit or laying-to stand. 3. Prior to initiating use of mechanical lift for a patient or resident: C. Determine how many caregivers are necessary to safely lift the patient or resident. In most cases and for safety, a minimum of 2 caregivers is recommended.

Based on observations, interviews and record review the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to ensure resident safety for 1 of 6 residents (Resident #3) reviewed for transfers with mechanical lifts. CNA I attempted to transfer Resident #3 alone using a Hoyer lift, when resident straightened out her legs she slid out of the sling onto the floor, as a result Resident #3 sustained fractures to the right tibia and right fibula. This failure resulted in actual harm to Resident #3 on 03/10/19. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents requiring the use of mechanical lifts for transfers at risk for injury due to staff not following facility policy and using 2 staff members for transfer anytime a Hoyer Lift transfer is required. Findings included: Review of Resident Face Sheet for Resident #3 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 was unable to participate in the Brief Interview for Mental Status (BIMS) indicating she had severe cognitive impairment. MDS indicated her speech was unclear, she was rarely able to make herself understood and she was able to understand others at times. MDS indicated she was totally dependent on two people and a Hoyer Lift for transfers. She required extensive assistance of two people for bed mobility, toileting, and personal hygiene. Resident #3 was dependent on one person for bathing and dressing. MDS also indicated Resident #3 was always incontinent of urine and bowel. Review of Resident #3's care plan dated 06/25/18 and reviewed on 02/20/19, to continue plan of care, indicated Resident #3 was at risk for falls related to right sided [MEDICAL CONDITION], Hoyer lift transfer, and cognitive impairment. The Long Term Goals was listed as, I will be free from major injury from fall. The Approach's were listed as: - Assess for medications which may be contributing factor - Encourage to use call light as needed and assist with ADL's as needed. Place call light within easy reach of me while in room. - Monitor for 72 hours post fall for any injuries that could be fall related. - Neuro checks for any unwitnessed fall when I cannot tell you that I hit my head or not. - Notify physician of falls. - Report changes in endurance, positioning, and transfers to PT/OT Review of the Facility Incident/Accident Investigation Worksheet dated 03/10/19 revealed CNA I was getting Resident #3 up when resident straightened her leg out and slipped out of the sling and fell on to the floor. The Physician and family were notified. Record review of the SBAR Communication Form dated 03/10/19 and written by LVN G revealed the following: The change in condition started on 03/10/19. Her primary diagnose were cerebral infarction unspecified and other [MEDICAL CONDITION]. Her vital signs were B/P 152/86, Pulse 70, Respirations 18, her temperature was 97.8?. It was documented there were no changes in Resident #3's mental status, functional status, behavioral evaluation, respiratory evaluation, cardiovascular evaluation, pain and neurological evaluation. There was no bruising or swelling or complaints of pain. Observation on 03/26/19 at 2:45 p.m. Resident #3 was sitting up in her wheelchair with her right lower extremity elevated and an immobilizer was noted to that extremity. Observation on 4/4/19 at 3:50 p.m. Resident #3 was sitting in her wheelchair with her right leg elevated. Immobilizer was in place. She was sitting in the lobby with her husband, she was clean well groomed, she was friendly and approachable. Observation and interview on 04/09/19 at 10:35 a.m. Resident #3 was lying in her bed, she was receiving am care. The CNA said that she was getting her up. Resident #3 nodded her head yes when asked if she was doing ok. She also nodded her head yes when asked if her right leg was hurting. Resident #3 was clean well groomed. Her clothes were clean and in good repair. Her room was clean and uncluttered. She had fluids at bedside and her call light was within reach. Review of Incident/Accident Investigation Witness statement dated 03/10/19, CNA I documented the following. I was transferring resident to her wheelchair when she straightened her leg that's when she slipped out of the sling. As soon as resident fell I called for help. CNA I could not be reached for an interview as her telephone number was no longer in service, per recording. In an interview on 04/02/19 at 8:30 a.m. with DON B she said that she was acting as an interim at the current time. She said that Administrator A and DON B should have investigated the incident on 03/10/19 involving Resident #3, the fall from the Hoyer Lift. She said the facility/corporate policy is that two people are required at all times to assist in the transfer of a resident while using the Hoyer Lift. In an interview on 04/04/19 at 10:30 a.m. with the CSD she said that regarding the incident on 03/10/19 with Resident #3, the CNA was transferring Resident #3 by herself using a Hoyer Lift, which is against company policy. She said that there should always be two people when using the HL. She said there would never be an exception to that rule unless there was a need of three people, but never one person alone. In an interview on 04/04/19 at 3:30 p.m. with Resident #3's husband he said the facility called him that morning (03/10/19) to notify him that Resident #3 had slipped out of the Hoyer Lift sling and fell to the floor while the CNA was transferring her from the bed to the wheelchair. He said that the nurse told him that the aide was using the Hoyer lift and she was transferring Resident #3 by herself. He said the nurse told him that Resident #3 was okay that she was not in any pain. He said that it is hard to tell when Resident #3 is any pain because she is not a complainer. He said that she has paralysis in her right leg because of a previous stroke. He said that she just does not feel pain the way most people do. He said that seven (7) days have passed from the time that she fell until the facility got x-rays and transferred her to the hospital. He said that leg had been broken two other times at another local nursing home. He said that day when he saw how swollen her leg was he knew it was broken. He said that he spoke with Administrator A at the time of transfer and he said she told him well accidents happen. He said but this is one accident that should have not happened, it could have been avoided. He said the aide should not have been transferring Resident #3 with a Hoyer lift all by herself. Record Review of Resident #3's Nurses Notes dated 03/10/19 6:00 a.m. - 6:00 p.m. shift and written by LVN F indicated no complaints of pain, status [REDACTED]. neuro checks within normal limits. Will monitor. Record Review of Resident #3's Nurses Notes dated 03/15/19 at 8:40 p.m., and written by LVN G revealed the following: Resident #3's husband stated his wife was in pain and that her right leg is swollen and requesting x-ray. Spoke with husband explained the situation and asked him if he wanted to send Resident #3 to the emergency room (ER). Record Review of Nurses Notes dated 03/16/19 late entry for 4:00 a.m. and written by LVN H. CNA reported resident complained of pain during turning, facial grimacing, nodded head when asked if she was in pain. Administered PRN Tylenol 325 mg PO per MD order Resident only complains of pain with movement to right leg. Right leg [MEDICAL CONDITION] 3+, shiny and warm to touch. Bruising noted below right knee down the ankle. Resident was not gotten up this am per husband request. Have reported to on-coming nurse regarding husband's requests and possible sending resident to the ER. Review of Resident #3's Physician order [REDACTED]. Review of Resident #3's Portable x-ray results taken on 03/16/19 at 9:57 a.m. revealed there were three views taken of Resident #3's right leg; Impression: Fractures of the tibia and fibula. X-ray; three views of the right knee; Impression: Acute fractures of the tibia and fibular neck. X-ray of right foot (3 or more views) Impression: Osteopenia. Repeat imaging in 7-10 days would be recommended if pain persists given the underlying osteopenia. Record Review of the Nurses Notes dated 03/16/19 at 2:00 p.m. and written by RN C revealed the following: Resident #3 was noted to have a swollen right leg. That is tender to touch, warm to feel, and expressing excruciating pain with movement. Orders were received to carry out x-ray from the hip down. X-ray results were received and Resident #3 was noted to have some fractures to the tib/fib and femur. Further orders received to transfer Resident #3 to the local hospital to the Emergency Department (ED)for further evaluation and care. Family aware of finding. In an interview on 04/02/19 at 4:45 p.m. with the Clinical Service Director (CSD) regarding the incident with Resident #3 she said that the incident report (IR dated 03/16/19) identified that Resident #3 had a fracture of unknown origin. She said it was reported that her leg was swollen and bruised and tender to touch. She said that an x-ray was taken at the facility and it was confirmed that Resident #3 had fractures to the tibia and fibular neck with underlying osteopenia. She said apparently the affected site had been fractured several times before. She said as she was investigating the cause of the fractures, she discovered there was an incident involving the Hoyer Lift. She said Resident #3 had an incident earlier in the month on 03/10/19 where she slipped out of the mechanical lift sling. She said it was reported to Administrator A and DON A that there was not any injury at that time. She said that Resident #3 had not complained of any pain until that Friday (3/15/19). She said that Resident #3's right leg was swollen. She said that day, Friday 3/15/19, they started doing competency training for transferring with the Hoyer Lift with the nursing staff, which required the staff to do a return demonstration. She said they also began in-servicing all staff on abuse and neglect on that Saturday (3/16/19). She said that it was her understanding that the nurse aide was using the Hoyer Lift by herself when the incident with Resident #3 occurred. She said it was the company policy that two people are required to transfer with the Hoyer Lift. She said that CNA I, the aide that was using the Hoyer Lift by herself when transferring Resident #3 quit and didn't come back. She said that she had made several attempts to speak with CNA I over the phone and at the facility, but she did not hear from her. She said CNA I did work a few nights after the incident, but she is not sure how many. She said she believes that CNA I got scared once it was determined that Resident #3 had a fracture that's when she left a note saying she was not coming back. She said she had not spoken with CNA I at all. She said that the CNAs should have competency training for transferring with the Hoyer Lift upon hire, annually and as needed when something comes up. She said they should do the competency check off before they are allowed to use the Hoyer Lift. She said that they did do competency training with CNA I on 3/14/19. She said that she did review CNA I's personnel file and there was a competency checklist done for transferring with a Hoyer Lift when she was first hired 11/16/17. During observation and interview on 04/04/19 at 12:55 p.m. with CNA E and CNA B as they were transferring a resident to bed from the wheelchair using the Hoyer Lift, CNA E said the only way a resident could slide out of the sling is not having them positioned properly in the sling or not having the sling properly hooked to the lift. CNB B agreed and said that it was most likely that the resident was not positioned in the sling properly. She said that the facility did have one sling that was different than the others. She said you had to crisscross the strap and weave it between the resident's legs. She said since the incident on 03/10/19 with Resident #3 that sling has been pulled off the floor. She said that now all their slings are the same. She said that every resident has their own sling. She said there were six residents that require a Hoyer Lift for transfers. During observation and interview on 04/04/19 at 1:05 p.m. with CNA F and CNA C as they were transferring a resident from the Geri-chair to the bed using the Hoyer Lift, CNA F said that the only way a resident could slip out of a sling is to not have them positioned properly. She said there must always be two people when transferring a person using a Hoyer Lift. CNA C agreed and said that since that accident all the CNAs have been in-serviced and how to use the Hoyer Lift properly. She said they had to do a return demonstration. She said that the facility has plenty of slings now that every resident has their own sling. Observation/interview on 04/04/19 at 1:20 p.m. CNA G and CNA C were transferring a resident from the wheelchair to the bed. CNA G said that there should always be two people using a Hoyer Lift during a transfer. She said there were no exceptions. She said that is not new that every place she had ever worked those are the rules. CNG G said no one can transfer by themselves when using a Hoyer Lift. She said they have plenty of slings now, that everyone has their own sling. She said they always remove the lift slings when they are laying a resident down in bed. She said that she had heard about the incident with Resident #3 and the only way she could have slid out of that sling is for the sling not to be on the lift's hooks properly or the resident was not positioned properly in the sling. She said that the incident was too bad, that Resident #3 should not had that happen to her, it was completely avoidable. In an interview on 04/02/19 at 4:40 p.m. with LVN A he said when using a Hoyer Lift there should always be two people. He said that there have not been any incidents regarding the Hoyer Lift on his residents, but he is aware that recently there was an incident where Resident #3 did slide out of the sling to the floor. He said the nursing staff have all been in-serviced on the proper use of Hoyer Lift. In an interview on 04/02/19 at 5:10 p.m. with LVN B he said that he is the one that does the training with the staff for transfers with the Hoyer Lift. He said there should always be two people regardless when the transfer requires the mechanical lift. He said there were different types of lift that works in different ways, which is why you should always use the Manufacturer's recommendations when using the lift. He said some of the lifts require the base to be open, others for the base to be closed, that's why you should be familiar with the lift you are using manufacture's recommendations for use. He said that no matter what lift you use or how you go about using it you should still always have two people when using any mechanical lift, otherwise it could cause a problem. In an interview on 04/09/19 at 3:30 p.m. the Interim Administrator, the Interim DON, and the CSD said their expectation was for staff to Resident #3's Plan of Care utilizing the appropriate interventions for that resident. Nurses were also available to assist nurses' aides in providing care to residents. She said that CNA I should have requested assistance of the other aides and/or nurse to care for Resident #3. She said that Resident #3 required assistance of two staff for her care. Review of CNA I's personnel file revealed she was hired in the Nursing Department on 11/16/17 for the 10:00 p.m. - 6:00 a.m. shift. There were all the necessary background checks completed without issue. There was a signed Job Description for Certified Nursing Assistant. Her NA certification was active without stipulations. There was a signed Hoyer Lift competency check list dated 11/16/17, that indicated CNA I had met the expected goals for competency. (All columns were checked off under the met column). Review of C.N.A. Competency Check List dated 03/14/19 indicated that CNA I had been checked off for Hoyer Lift Transfers. Review of in-service dated 03/10/19 at 5:30 a.m. revealed the following: Anytime a lift is used there must be 2 people assisting at all times, no excuses! Thirteen (13) staff members signed the attendance sheet. Review of Resident #3's Physician order [REDACTED]. Review of the Nursing Policy & Procedure dated 03/27/18 for Mechanical Lifts revealed the following: Policy: The facility may employ the use of mechanical lifts to assist with transfers to ensure the safety of patients, residents and staff. Scope: Mechanical lifting equipment includes any permanently mounted or portable/floor-based lifts that may be either powered or manual, used to transfer or move patients/residents. Procedure: 1. Prior to using any mechanical lift device, competence must be documented in the safe and appropriate use of the equipment per policy and manufacturer guidelines, specific to the device. Mechanical lifts may be used for the enhanced safety of patients, residents and staff in situations including but not limited to: A. Lifting from floor. B. Bed to chair transfers. C. Lateral transfers. D. Toileting and bathing. E. Repositioning. F. Sit or laying-to stand. 2. Prior to initiating use of mechanical lift for a patient or resident: C. Determine how many caregivers are necessary to safely lift the patient or resident. In most Cases and for safety, a minimum of 2 caregivers is recommended.

Based on record review and interview the facility failed to honor the resident's right to refuse treatment for one (Resident #1) of 14 residents reviewed for advanced directives. The facility failed to follow their policies and procedures to identify resident code status. On [DATE] an Out of Hospital Do Not Resuscitate (OOH-DNR) form was completed for Resident #1. The facility Social Services Director failed to place the form in the resident's chart, so it was not accessible to staff. On [DATE] Resident #1 experienced a witnessed [MEDICAL CONDITION]. CPR was conducted by facility staff, and the resident was transported to the hospital where she was pronounced deceased . This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure could affect 42 residents who had implemented Advanced Directives establishing their desire not to be resuscitated, placing them at risk for receiving CPR against their wishes, which can result in broken bones, internal organ damage or leave the resident in a vegetative state. Findings included: Closed record review of Resident #1's face sheet dated [DATE] indicated she was an [AGE] year-old female who was admitted to the facility on [DATE]. The Advanced Directives section of the face sheet showed Resident #1 to have a living will and a do not resuscitate (DNR), with copies of both documents on file. Review of Physician order [REDACTED].#1's [DIAGNOSES REDACTED]. The order also indicated a code status of DNR with a start date of [DATE]. Review of Resident #1's admission orders [REDACTED]. Review of physician telephone order dated [DATE] indicated a code status of DNR. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 7 indicating a severe cognitive impairment. The MDS also showed Resident #1 required extensive assistance of one person for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. Review of Resident #1's care plan section for advanced care planning dated [DATE], created by Social Services Director (SSD), and updated on [DATE] by SSD, indicated long term goals of: resident will be informed of his/her right to complete advanced directives to direct his(sp) medical care and make his(sp) values and treatment goals known. Residents stated desires will be honored. The approach, dated [DATE] and created by SSD included: advanced directives of residents choice completed and physician notified of residents desires and any needed physicians order obtained. Resident has completed the following advanced directives: DNR, living will, and medical power of attorney. Review of Social Services Admission Evaluation form dated [DATE] for Resident #1, signed by SSD, indicated the resident had the following advance directives: living will, healthcare proxy and DNR. Adjacent to DNR 'yes' is checked to show a copy was obtained. Review of Resident #1's Care Plan Conference Summary dated [DATE] listed DNR for advance directives/code status. Review of Resident #1's Social Service Progress Note dated [DATE] revealed, .Advanced directives have been reviewed and no changes indicated. Code status is DNR. Review of Resident #1's Social Service Progress Notes dated [DATE] revealed, .advanced directives have been reviewed (and) no changes indicated. SSD will assist in a new DNR d/t (due to) legibility . Review of Resident #1's Social Service Progress Notes dated [DATE] revealed, .has no changes with advanced directives (and) code status is DNR. SSD continues to wait on signatures to execute an (sp) DNR . Review of Social Service Review dated [DATE] by LBSW, for Resident #1 indicated code status DNR-not properly executed-SS (SSD) has new one. Review of Resident #1's clinical record revealed a Texas Department of State Health Services Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) executed by the resident on [DATE], Living Will documents dated [DATE], and a Texas Department of State Health Services OOH-DNR executed by Resident #1's medical power of attorney dated [DATE] and signed by Resident #1's physician on [DATE]. Review of Social Service Progress Review, dated [DATE], for Resident #1 listed in the advance directive/code status section, indicated a code status of DNR, OOH-DNR. In telephone interviews on [DATE] at 3:02 pm and [DATE] at 11:55 am, SSD said there was confusion about Resident #1's code status. She said the resident had come from another facility and brought the OOH-DNR with her. It was determined (at some point) to have an error as the physician signed on the wrong line. SSD said she approached Resident #1's son to explain the error and have a new OOH-DNR completed. SSD said she knew she received the new document because she provided a copy of it to the resident's son. SSD said anytime there was an update of information for a resident, she would update the resident's face sheet and put it on their chart. She said there is a date at the bottom of the face sheet indicating when it was printed. SSD said she is not sure if she put the new OOH-DNR on Resident #1's chart. Review of Nurse's Notes for Resident #1 dated [DATE], 7:30 pm revealed Resident transferring self from recliner to WC (wheelchair). Had CNA take resident to bathroom. 8:00 pm CNA stated she's not acting right. Brought resident to nurses station. BP (blood pressure) ,[DATE]-45 then no BP. Called for EMS. Started CPR. Continue CPR x (times) 15 minutes before EMS arrived and continued CPR. Left facility via ambulance approx. (approximately) 8:30 pm. Notified MD (medical doctor), DON (director of nursing) and son. APD (Abilene Police Department) here during and after CPR. APD spoke to physician A on phone. Signed LVN A In a telephone interview on [DATE] at 5:13 pm, LVN A said on [DATE] Resident #1's face sheet said DNR, however, there was no red/green code status indicator sheet or OOH-DNR on her chart so they had to perform CPR. LVN A said if the OOH-DNR is not on the resident's chart, it does not exist. She said you have to have the OOH-DNR in order to not do CPR. LVN A said emergency services (EMS) came to the facility promptly and continued to administer CPR and the resident was pronounced deceased at the hospital. In an interview on [DATE] at 1:10 pm, Director of Nursing (DON) said staff are to pull the resident's chart and look for the green (indicates full code) or red (indicates DNR) flash sheet. She said if there is a red flash sheet, staff should proceed to verify an OOH-DNR is on the chart. DON said if there is a red (DNR) flash sheet and no OOH-DNR, the incident should be worked as a full code and CPR initiated. She said if a resident has an episode (a situation where CPR would potentially be needed), the OOH-DNR is copied and provided to EMS upon their arrival at the facility. DON said SSD told her the DNR red flash sheet and OOH-DNR had been in Resident #1's chart because she had provided a copy to the resident's son over the weekend prior to the incident. DON said SSD told her the documents should be in Resident #1's chart or they were on her desk. The SSD was suspended then terminated the following day. In an interview on [DATE] at 3:50 pm, Administrator said SSD told her she had placed the OOH-DNR for Resident #1 in her chart. Administrator said the nurse did not find the DNR or the red flash sheet in Resident #1's chart. Administrator said the facility staff have to have a signed Texas OOH-DNR on the resident's chart to not initiate CPR. She said there was some confusion as the old OOH-DNR for Resident #1 had not been signed correctly so the SSD started the process of getting a new one completed which the resident's son took some time before returning. Administrator said SSD found a copy of the new OOH-DNR in SSD's file but was not able to locate the original. Administrator said SSD was responsible for updating and maintaining code status information on resident clinical charts. Review of SSD's personnel file revealed an email correspondence dated [DATE] between Administrator and Human Resources regarding the status of SSD's employment. The administrator wrote .the latest issue with the DNR not being on the chart will result in a deficiency from the state . The response received was in agreement to terminate SSD with a focus on the DNR that was not in the resident's chart as well as other performance concerns. In a telephone interview on [DATE] at 10:09 am, Resident #1's son said his mother had an OOH-DNR from 2012 that was provided to the facility upon her admission. He said in late October he was approached by facility staff about an error in the OOH-DNR due to the physician signing in an incorrect location. He said a new OOH-DNR was executed and the SSD had provided him with a copy of it the weekend before the incident. The son said the night Resident #1 became unresponsive, he received a call from the facility regarding her condition and advising they initiated CPR because they did not have an OOH-DNR. He said he was confused by them doing CPR because he had a copy of the OOH-DNR dated [DATE] that he had received from SSD. The son said his mother's body was so fragile. He said she did not want to have CPR done that is why she had the OOH-DNR. Review of Resident #1's local hospital emergency room record revealed the resident was presented to their emergency room via ambulance on [DATE] at 8:43 pm. The record stated the resident was intubated, unresponsive, code. Additional HPI (history and physical information) included: Per EMS, patient experienced a witnessed [MEDICAL CONDITION] at the nurse's station. Although patient is a DNR, paperwork could not be provided/found, so CPR was initiated .At time of arrival to ED (Emergency Department) at 8:43 pm, patient had experienced 40 minutes of downtime .At 8:58 pm resident was pronounced deceased . Review of facility policy titled Nursing Policies and Procedures, revised [DATE] revealed: Subject: Do Not Resuscitate (DNR) Policy: Facility staff will follow the resident's Advance Directives in accordance with applicable law and regulation as well as the applicable Facility Policies and Procedures. Each resident's medical record will be flagged in a standardized manner to identify the resident's code status as DNR or FULL CODE. PR(NAME)EDURES: 1. At the time of admission .to the Facility, Social Services or a Nursing Designee will review the resident's transfer summary, if any, for any documentation regarding the resident's code status, including but not limited to a valid DNR order and . 2. At the time of admission .to the Facility, Social Services or a Nursing Designee will meet with the resident and/or his/her legal representative (in the order and manner prescribed by State-specific regulations) to thoroughly review the State and the Facility protocols for advanced directives, including the resident's right to determine whether or not he/she wishes to be resuscitated in the event he/she suffers cardiac or respiratory arrest. 3. If a DNR order on the State's prescribed form (if applicable) already exists AND the resident wants the order to continue in effect, Social Services or a Nursing Designee will promptly obtain a copy of the DNR order, ensure the necessary written certifications are in the medical record and follow the protocols below for identifying the resident as a DNR except that, if a resident is admitted to the Facility with a properly executed and valid DNR order on the State's prescribed form (if applicable), no further information shall be required and the resident shall be identified as a DNR . 6. Once a DNR order has been finalized by obtaining the proper written certifications and the necessary orders from the resident's treating physician, Social Services or a Nursing Designee will follow the protocols below for identifying the resident's code status as a DNR. Social Services and Nursing Designee are also responsible for ensuring that the State-prescribed form (if applicable) is properly completed and included in the resident's file within ten (10) days of the resident's election of DNR status . 8. Social Services and Nursing Designee are responsible for ensuring that each resident's code status is properly documented and displayed on the Resident's medical record. DNR. To signify a resident is not to be resuscitated, the Facility will prominently note the medical record by placing a red sticker or red flash sheet designating DNR on the inside cover of the file . FULL CODE. To signify a resident is a FULL CODE and should be resuscitated, the Facility will prominently note the file by placing a green sticker or green flash sheet designating Full Code on the inside cover of resident's medical record . 10. Social Services or a Nursing Designee will promptly notify the Facility Administrator if the resident's code status is not confirmed with the appropriate paperwork on the resident's medical record It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from [DATE] to [DATE]. The following actions were taken by the facility prior to this investigation: PERFORMANCE IMPROVEMENT PLAN Issue Identified: Code Status of Resident was not clearly identified-Out of Hospital Do Not Resuscitate Form was not in Medical Record. I. Identified resident no longer resides in the facility. II. Residents with Do Not Resuscitate Code status have the potential to be affected by the alleged deficient practice. III. An audit of current resident charts was conducted by 4pm on [DATE] to validate that code status is accurate. IV. Director of Nursing or designee will provide re-education to license nursing staff on the Cardiopulmonary Resuscitation, Emergency Code Blue Policy and the process for identifying the code status of a resident. V. The Administrator or designee will provide re-education to Director of Social Services on the process for identifying the code status of a resident in the medical record to include the proper inclusion of the Out of Hospital Do No Resuscitate Form and Red/green identifier. VI. 100% of current resident's medical records will be audited by licensed nurses for accuracy of identification of code status by 4 PM on November21, 2017. Any resident with a Do Not Resuscitate code status that does not have and Out of Hospital Do Not Resuscitate form properly signed and in the medical record or that is not clear will be corrected. The code status will be confirmed and the order will be present in the medical record for Do Not Resuscitate or Full Code. Red/green identifiers will also be validated to be correct and consistent with code status and Care Plans will be updated to reflect current code status by licensed nurses and/or social worker by 5 pm on [DATE]. Certified and Licensed staff's re-education includes the location of code status identifiers: red/green identifiers are located in the front of the resident's chart and on the Kiosk (Electronic medical record, computers are on each hall and in the dining room all staff has access to the Residents record). VII. The facility will assess residents having the potential to be affected by this practice, including: An audit was completed of any resident having cardiopulmonary resuscitation done or being pronounced to determine if code status was followed, for the last 60 days.- No issues were identified. VIII. Licensed Nurses were re-educated by Director of Nursing/Designee regarding code status identifiers and policy by 2 pm on [DATE]. Licensed Nurses, Certified Nurse's Aides, and Certified Medication Aides will be re-educated by Director of Nursing/designee regarding code status by 2 pm on [DATE]. No nurse staff will be allowed to work after 2 pm on [DATE] until they receive the required education. This information will be provided in new hire orientation and all new hires will receive this education before allowed to work. IX. Director of Nursing/designee will monitor charts of all new admissions and re-admissions within 72 hours of admit to validate code status and that status is identified following policy. The process will begin on [DATE]; will be done daily for the next 30 days, two times a week for 30 days and then randomly thereafter. Any areas of concern will be addressed at the time of discovery. X. Medical Director was notified and an Ad Hoc Quality Assurance Performance Improvement Committee meeting will be held on [DATE]. XI. Director of Nursing/designee will report progress to Quality Assurance Performance Improvement Committee monthly times 3 months and until compliance has been achieved. The next Quality Assurance Performance On [DATE] the surveyor verified the above actions had been completed through interviews and record reviews. Review of facility chart audit report dated [DATE] provided by DON indicates all resident charts were audited for green/red flash sheets, code documents (OOH-DNR), physician orders [REDACTED]. Review of in-service documentation dated [DATE] titled CPR, Emergency Code Blue was attended by 36 staff members. Review of twelve randomly selected clinical records between [DATE] and [DATE] for current residents revealed all proper documents related to code status were in place on their chart. Interviews held between [DATE] and [DATE] with one registered nurse (RN) and four LVN's representing different shifts, the DON and administrator revealed all were aware of the documents necessary for a resident's code status and the policy and procedure for administering a full code or DNR. Review of code status report dated [DATE] provided by DON revealed 42 residents with a DNR status.

Based on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible and systematically organized for one (Resident #1) of 14 residents reviewed for advanced directives. The facility failed to maintain accurate, complete and readily accessible medical records to identify resident code status. On [DATE] an Out of Hospital Do Not Resuscitate (OOH-DNR) form was completed for Resident #1. The facility Social Services Director failed to place the form in the resident's chart, so it was not accessible to staff. On [DATE] Resident #1 experienced a witnessed [MEDICAL CONDITION]. CPR was conducted by facility staff, and the resident was transported to the hospital where she was pronounced deceased . This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure could affect 42 residents who had implemented Advanced Directives establishing their desire not to be resuscitated, placing them at risk for receiving CPR against their wishes which can result in broken bones, internal organ damage or leave the resident in a vegetative state. Findings included: Closed record review of Resident #1's face sheet dated [DATE] indicated she was an [AGE] year-old female who was admitted to the facility on [DATE]. The Advanced Directives section of the face sheet showed Resident #1 to have a living will and a do not resuscitate (DNR), with copies of both documents on file. Review of Physician order [REDACTED].#1's [DIAGNOSES REDACTED]. The order also indicated a code status of DNR with a start date of [DATE]. Review of Resident #1's admission orders [REDACTED]. Review of physician telephone order dated [DATE] indicated a code status of DNR. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 7 indicating a severe cognitive impairment. The MDS also showed Resident #1 required extensive assistance of one person for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. Review of Resident #1's care plan section for advanced care planning dated [DATE], created by Social Services Director (SSD), and updated on [DATE] by SSD, indicated long term goals of: resident will be informed of his/her right to complete advanced directives to direct his(sp) medical care and make his(sp) values and treatment goals known. Residents stated desires will be honored. The approach, dated [DATE] and created by SSD included: advanced directives of residents choice completed and physician notified of residents desires and any needed physicians order obtained. Resident has completed the following advanced directives: DNR, living will, and medical power of attorney. Review of Social Services Admission Evaluation form dated [DATE] for Resident #1, signed by SSD, indicated the resident had the following advance directives: living will, healthcare proxy and DNR. Adjacent to DNR 'yes' is checked to show a copy was obtained. Review of Resident #1's Care Plan Conference Summary dated [DATE] listed DNR for advance directives/code status. Review of Resident #1's Social Service Progress Note dated [DATE] revealed, .Advanced directives have been reviewed and no changes indicated. Code status is DNR. Review of Resident #1's Social Service Progress Notes dated [DATE] revealed, .advanced directives have been reviewed (and) no changes indicated. SSD will assist in a new DNR d/t (due to) legibility . Review of Resident #1's Social Service Progress Notes dated [DATE] revealed, .has no changes with advanced directives (and) code status is DNR. SSD continues to wait on signatures to execute an (sp) DNR . Review of Social Service Review dated [DATE] by LBSW, for Resident #1 indicated code status DNR-not properly executed-SS (SSD) has new one. Review of Resident #1's clinical record revealed a Texas Department of State Health Services Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) executed by the resident on [DATE], Living Will documents dated [DATE], and a Texas Department of State Health Services OOH-DNR executed by Resident #1's medical power of attorney dated [DATE] and signed by Resident #1's physician on [DATE]. Review of Social Service Progress Review, dated [DATE], for Resident #1 listed in the advance directive/code status section, indicated a code status of DNR, OOH-DNR. In telephone interviews on [DATE] at 3:02 pm and [DATE] at 11:55 am, SSD said there was confusion about Resident #1's code status. She said the resident had come from another facility and brought the OOH-DNR with her. It was determined (at some point) to have an error as the physician signed on the wrong line. SSD said she approached Resident #1's son to explain the error and have a new OOH-DNR completed. SSD said she knew she received the new document because she provided a copy of it to the resident's son. SSD said anytime there was an update of information for a resident, she would update the resident's face sheet and put it on their chart. She said there is a date at the bottom of the face sheet indicating when it was printed. SSD said she is not sure if she put the new OOH-DNR on Resident #1's chart. Review of Nurse's Notes for Resident #1 dated [DATE], 7:30 pm revealed Resident transferring self from recliner to WC (wheelchair). Had CNA take resident to bathroom. 8:00 pm CNA stated she's not acting right. Brought resident to nurses station. BP (blood pressure) ,[DATE]-45 then no BP. Called for EMS. Started CPR. Continue CPR x (times) 15 minutes before EMS arrived and continued CPR. Left facility via ambulance approx. (approximately) 8:30 pm. Notified MD (medical doctor), DON (director of nursing) and son. APD (Abilene Police Department) here during and after CPR. APD spoke to physician A on phone. Signed LVN A In a telephone interview on [DATE] at 5:13 pm, LVN A said on [DATE] Resident #1's face sheet said DNR, however, there was no red/green code status indicator sheet or OOH-DNR on her chart so they had to perform CPR. LVN A said if the OOH-DNR is not on the resident's chart, it does not exist. She said you have to have the OOH-DNR in order to not do CPR. LVN A said emergency services (EMS) came to the facility promptly and continued to administer CPR and the resident was pronounced deceased at the hospital. In an interview on [DATE] at 1:10 pm, Director of Nursing (DON) said staff are to pull the resident's chart and look for the green (indicates full code) or red (indicates DNR) flash sheet. She said if there is a red flash sheet, staff should proceed to verify an OOH-DNR is on the chart. DON said if there is a red (DNR) flash sheet and no OOH-DNR, the incident should be worked as a full code and CPR initiated. She said if a resident has an episode (a situation where CPR would potentially be needed), the OOH-DNR is copied and provided to EMS upon their arrival at the facility. DON said SSD told her the DNR red flash sheet and OOH-DNR had been in Resident #1's chart because she had provided a copy to the resident's son over the weekend prior to the incident. DON said SSD told her the documents should be in Resident #1's chart or they were on her desk. The SSD was suspended then terminated the following day. In an interview on [DATE] at 3:50 pm, Administrator said SSD told her she had placed the OOH-DNR for Resident #1 in her chart. Administrator said the nurse did not find the DNR or the red flash sheet in Resident #1's chart. Administrator said the facility staff have to have a signed Texas OOH-DNR on the resident's chart to not initiate CPR. She said there was some confusion as the old OOH-DNR for Resident #1 had not been signed correctly so the SSD started the process of getting a new one completed which the resident's son took some time before returning. Administrator said SSD found a copy of the new OOH-DNR in SSD's file but was not able to locate the original. Administrator said SSD was responsible for updating and maintaining code status information on resident clinical charts. Review of SSD's personnel file revealed an email correspondence dated [DATE] between Administrator and Human Resources regarding the status of SSD's employment. The administrator wrote .the latest issue with the DNR not being on the chart will result in a deficiency from the state . The response received was in agreement to terminate SSD with a focus on the DNR that was not in the resident's chart as well as other performance concerns. In a telephone interview on [DATE] at 10:09 am, Resident #1's son said his mother had an OOH-DNR from 2012 that was provided to the facility upon her admission. He said in late October he was approached by facility staff about an error in the OOH-DNR due to the physician signing in an incorrect location. He said a new OOH-DNR was executed and the SSD had provided him with a copy of it the weekend before the incident. The son said the night Resident #1 became unresponsive, he received a call from the facility regarding her condition and advising they initiated CPR because they did not have an OOH-DNR. He said he was confused by them doing CPR because he had a copy of the OOH-DNR dated [DATE] that he had received from SSD. The son said his mother's body was so fragile. He said she did not want to have CPR done that is why she had the OOH-DNR. Review of Resident #1's local hospital emergency room record revealed the resident was presented to their emergency room via ambulance on [DATE] at 8:43 pm. The record stated the resident was intubated, unresponsive, code. Additional HPI (history and physical information) included: Per EMS, patient experienced a witnessed [MEDICAL CONDITION] at the nurse's station. Although patient is a DNR, paperwork could not be provided/found, so CPR was initiated .At time of arrival to ED (Emergency Department) at 8:43 pm, patient had experienced 40 minutes of downtime .At 8:58 pm resident was pronounced deceased . Review of facility policy titled Nursing Policies and Procedures, revised [DATE] revealed: Subject: Do Not Resuscitate (DNR) Policy: Facility staff will follow the resident's Advance Directives in accordance with applicable law and regulation as well as the applicable Facility Policies and Procedures. Each resident's medical record will be flagged in a standardized manner to identify the resident's code status as DNR or FULL CODE. PR(NAME)EDURES: 1. At the time of admission .to the Facility, Social Services or a Nursing Designee will review the resident's transfer summary, if any, for any documentation regarding the resident's code status, including but not limited to a valid DNR order and . 2. At the time of admission .to the Facility, Social Services or a Nursing Designee will meet with the resident and/or his/her legal representative (in the order and manner prescribed by State-specific regulations) to thoroughly review the State and the Facility protocols for advanced directives, including the resident's right to determine whether or not he/she wishes to be resuscitated in the event he/she suffers cardiac or respiratory arrest. 3. If a DNR order on the State's prescribed form (if applicable) already exists AND the resident wants the order to continue in effect, Social Services or a Nursing Designee will promptly obtain a copy of the DNR order, ensure the necessary written certifications are in the medical record and follow the protocols below for identifying the resident as a DNR except that, if a resident is admitted to the Facility with a properly executed and valid DNR order on the State's prescribed form (if applicable), no further information shall be required and the resident shall be identified as a DNR . 6. Once a DNR order has been finalized by obtaining the proper written certifications and the necessary orders from the resident's treating physician, Social Services or a Nursing Designee will follow the protocols below for identifying the resident's code status as a DNR. Social Services and Nursing Designee are also responsible for ensuring that the State-prescribed form (if applicable) is properly completed and included in the resident's file within ten (10) days of the resident's election of DNR status . 8. Social Services and Nursing Designee are responsible for ensuring that each resident's code status is properly documented and displayed on the Resident's medical record. DNR. To signify a resident is not to be resuscitated, the Facility will prominently note the medical record by placing a red sticker or red flash sheet designating DNR on the inside cover of the file . FULL CODE. To signify a resident is a FULL CODE and should be resuscitated, the Facility will prominently note the file by placing a green sticker or green flash sheet designating Full Code on the inside cover of resident's medical record . 10. Social Services or a Nursing Designee will promptly notify the Facility Administrator if the resident's code status is not confirmed with the appropriate paperwork on the resident's medical record It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from [DATE] to [DATE]. The following actions were taken by the facility prior to this investigation: PERFORMANCE IMPROVEMENT PLAN Issue Identified: Code Status of Resident was not clearly identified-Out of Hospital Do Not Resuscitate Form was not in Medical Record. I. Identified resident no longer resides in the facility. II. Residents with Do Not Resuscitate Code status have the potential to be affected by the alleged deficient practice. III. An audit of current resident charts was conducted by 4pm on [DATE] to validate that code status is accurate. IV. Director of Nursing or designee will provide re-education to license nursing staff on the Cardiopulmonary Resuscitation, Emergency Code Blue Policy and the process for identifying the code status of a resident. V. The Administrator or designee will provide re-education to Director of Social Services on the process for identifying the code status of a resident in the medical record to include the proper inclusion of the Out of Hospital Do No Resuscitate Form and Red/green identifier. VI. 100% of current resident's medical records will be audited by licensed nurses for accuracy of identification of code status by 4 PM on November21, 2017. Any resident with a Do Not Resuscitate code status that does not have and Out of Hospital Do Not Resuscitate form properly signed and in the medical record or that is not clear will be corrected. The code status will be confirmed and the order will be present in the medical record for Do Not Resuscitate or Full Code. Red/green identifiers will also be validated to be correct and consistent with code status and Care Plans will be updated to reflect current code status by licensed nurses and/or social worker by 5 pm on [DATE]. Certified and Licensed staff's re-education includes the location of code status identifiers: red/green identifiers are located in the front of the resident's chart and on the Kiosk (Electronic medical record, computers are on each hall and in the dining room all staff has access to the Residents record). VII. The facility will assess residents having the potential to be affected by this practice, including: An audit was completed of any resident having cardiopulmonary resuscitation done or being pronounced to determine if code status was followed, for the last 60 days.- No issues were identified. VIII. Licensed Nurses were re-educated by Director of Nursing/Designee regarding code status identifiers and policy by 2 pm on [DATE]. Licensed Nurses, Certified Nurse's Aides, and Certified Medication Aides will be re-educated by Director of Nursing/designee regarding code status by 2 pm on [DATE]. No nurse staff will be allowed to work after 2 pm on [DATE] until they receive the required education. This information will be provided in new hire orientation and all new hires will receive this education before allowed to work. IX. Director of Nursing/designee will monitor charts of all new admissions and re-admissions within 72 hours of admit to validate code status and that status is identified following policy. The process will begin on [DATE]; will be done daily for the next 30 days, two times a week for 30 days and then randomly thereafter. Any areas of concern will be addressed at the time of discovery. X. Medical Director was notified and an Ad Hoc Quality Assurance Performance Improvement Committee meeting will be held on [DATE]. XI. Director of Nursing/designee will report progress to Quality Assurance Performance Improvement Committee monthly times 3 months and until compliance has been achieved. The next Quality Assurance Performance On [DATE] the surveyor verified the above actions had been completed through interviews and record reviews. Review of facility chart audit report dated [DATE] provided by DON indicates all resident charts were audited for green/red flash sheets, code documents (OOH-DNR), physician orders [REDACTED]. Review of in-service documentation dated [DATE] titled CPR, Emergency Code Blue was attended by 36 staff members. Review of twelve randomly selected clinical records between [DATE] and [DATE] for current residents revealed all proper documents related to code status were in place on their chart. Interviews held between [DATE] and [DATE] with one registered nurse (RN) and four LVN's representing different shifts, the DON and administrator revealed all were aware of the documents necessary for a resident's code status and the policy and procedure for administering a full code or DNR. Review of code status report dated [DATE] provided by DON revealed 42 residents with a DNR status.

Based on observation, record review and interview the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 resident (resident #3) of four residents reviewed for incidents. The facility failed to keep Resident #3 under supervision while up in her wheelchair. She had an unwitnessed fall from her wheelchair and required 5 sutures and 11 staples in her forehead and scalp. This failure could affect 33 resident who reside on the West Hall, placing them at risk for injury due to avoidable accidents. Findings include: Record Review of Resident #3's undated face sheet revealed an [AGE] year old female with most recent admission to the facility on [DATE] with [DIAGNOSES REDACTED]. She was on Hospice care. Record review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed she was unable to participate in the Brief Interview for Mental Status (BIMS) for cognition assessment. The staff assessment for mental status was completed; short term memory was okay, long term memory was a problem and she was unable to recall season, location of her room, staff names or faces or that she was in a nursing home. The ADL Functional Status section revealed Resident #3 needed extensive assistance of one person to move from place to place while in her wheelchair. The evaluation of Balance During Transition and Walking section revealed Resident #3 is not steady and only able to stabilize with staff assistance. Record Review of the Care Plan, dated 9/27/17 revealed 'Resident #3 was at risk for falls related to poor awareness, increase in dependency on staff for mobility and activities of daily living, poor balance and a history of falls'. Goal was to remain free from injury related to falls through the next review. Approach for all disciplines was to observe frequently and place in a supervised area when out of bed. Record review of the Resident Accident Investigation worksheet dated 10/13/17 at 8pm written by LVN D revealed Resident #3 had been alone in her room and had experienced an unwitnessed fall from her wheelchair. She had a laceration to her forehead. 911 was called for transport to a local hospital emergency room for evaluation and treatment. Interview on 10/31/17 at 11:40am with CNA D revealed she had been on duty the evening Resident #3 had fallen out of her wheelchair. CNA D and A were bringing residents back to their rooms after an activity in the dining room at approximately 8pm. CNA A was sent to the locked unit to work. Resident #3 was in her wheelchair in her room unattended. CNA D was in the next room assisting 2 residents to bed, when finished she went to Resident #3's room to find her face down on the floor in a pool of blood. She called LVN D for assistance. Interview on 10/31/17 at 4pm, over the phone, LVN D reported she had been passing medications when CNA D called loudly for her from Resident #3's room. LVN D said she saw Resident #3 face down on the floor in a pool of blood. She requested a damp cloth to place on Resident #3's forehead. She did a set of vital signs and called 911, family, Hospice and RN B. Resident #3 was transported to local hospital emergency room via ambulance. Interview on 10/31/17 at 8:30 am, RN B stated she had interviewed staff on 10/13/17 in the evening after 8:30pm. RN B said she spoke to CNA D about Resident #3's unwitnessed fall. CNA D had reported Resident #3 had been left in her room sitting unattended in her wheelchair. She was found on the floor with a laceration to her forehead on 10/13/17 at approximately 8pm. RN B interview with CNA A revealed he had been sent back to the locked unit to assist people back to bed. RN B interview with LVN D said she had seen Resident #3 sitting unattended in the hallway at her room door while she was passing medication. Review of the Hospital record revealed Resident #3 arrived at a local hospital emergency roiagnom on [DATE] at 8:39pm via ambulance. Doctor of Osteopathic Medicine (DO) documented assessment was of an 8 centimeter curved laceration to her right forehead and scalp. DO closed the wound with five retention sutures and eleven staples. Resident #3 was discharged from the emergency room to a hospital room for overnight observation and discharged back to nursing home on 10/14/17. Observation 10/31/17 at 4:50pm, Resident #3 on secure unit, sitting in her wheelchair at a dining room table. Sutures and staples to right forehead and scalp, no facial bruising noted. Staff and other residents in dining room. Record review of resident's chart on 10/31/17 at noon revealed there were no nurse's notes dated 10/13/17 regarding Resident #3's unwitnessed fall. LVN B was asked to locate the nurses notes for this resident dated 10/13/17 and 10/14/17. LVN B was unable to find nursing documentation for Resident #3 dated 10/13/17. Record review of Resident Bed List Report dated 10/31/17 revealed 33 people lived on the West Hall.

Based on interview and record review, the facility failed to implement their written policies and procedures for abuse/neglect prevention for three of seventeen residents (Resident #3, #15, and #16) reviewed for incidents of abuse/neglect as evidenced by: a. The facility failed to investigate, protect, and report allegations of abuse, LVN A physically and verbally abused Resident #3, #15, and #16. b. CNA A, B, and C failed to report and protect Residents #3 and #16 from being abused by LVN A. On 06/13/14 IJ was identified. While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of a potential for more than minimal harm and scope of "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. This failure could affect all 71 residents residing in the facility by placing them at risk for abuse or neglect. The findings included: Record review of the facility's Leadership Policies and Procedures: Abuse, Neglect and Misappropriation, revised on 05/01/13, revealed "The facility's Leadership prohibits neglect, mental or physical abuse ... The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and/or funds. The facility's Leadership will provide notification to the proper authorities . . . The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident . . ." According to the facility's abuse policy "staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types of abuse include but are not limited to physical assault/abuse . . . mental abuse . . . verbal abuse . . . neglect . . . All alleged violations concerns abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator . . . and other enforcement agencies according to state law including the State Survey and Certification Agency . . . The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken . . . The investigation may include but is not limited to the following: Identification and removal of the alleged perpetrators . . .Written summaries of interviews with individuals having firsthand knowledge of the incident . . . Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer . . .In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process . . . Guidelines for Investigation: Immediately assess the resident/patient at the time of discovery of alleged abuse. Document assessment in the medical record. Maintain the resident's/patient's protection during the investigation . . . Protection: During the investigation, the facility protect the patient/resident, as appropriate, including but not limited to the following: Removal of the alleged abuser from the patient/resident care setting. Enforcing a zero tolerance standard for retaliation against the alleged victim." Resident #3 Record review of Resident #3's Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 3/17/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) could not be conducted because Resident #1 was rarely/never understood. Under C1000 Cognitive Skills for Daily Decision Making revealed that Resident #3 had scored a "3" , indicating her cognition was severely impaired with making decision regarding task of daily life. Section G: Activities of Daily Living (ADL) Assistance, G0110 indicated Resident #3 was totally dependent with the assistance of one staff with eating/drinking. In an observation on 6/13/14 at 1:20 p.m., revealed Resident #3 lying in bed with head of bed elevated at 15 degrees. Resident #3 was asked her name or how she was doing by surveyor, Resident #3 would just look at her television and would not acknowledged surveyor was present in the room. No obvious injuries or suspicious bruising was noted on body. Resident #3 appeared well groomed. Resident #15 Record review of Resident #15's Admission Record Sheet, undated, revealed a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 5/02/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) score as "0", indicating Resident #15's cognition was not intact. Section E: Behavior reflected Resident #15 did not exhibit physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others. Section G: Functional Status indicated Resident #15 required extensive assistance of one person with bed mobility, and extensive assistance of two or more person physical assistance for transfers. Resident #16 Record review of Resident #16's Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 4/17/14, reflected Resident #16's Brief Interview for Mental Status (BIMS) score as "99" , indicating Resident #16 was unable to complete interview. Under C1000 Cognitive Skills for Daily Decision Making revealed that Resident #16 had scored a "3" , indicating her cognition was severely impaired with making decision regarding task of daily life. Section G Functional Status indicated Resident #16 required extensive assistance of two or more person physical assistance for bed mobility and transfers. In an observation on 6/19/14 at 9:43 a.m., revealed Resident #16 sitting up in her wheelchair in the dining room in the locked unit. Resident #16 did not know her name or where she was at. All Resident #16 would say was that "it's kind of cold". A CNA brought Resident #16 a blanket and covered her legs. No obvious bruising or suspicious injuries were noted on Resident #16. Interviews: In an interview on 6/11/14 at 12:08 p.m., CNA A stated that if she saw a resident being abused by another staff member, she was trained to report it immediately and protect the resident by removing resident from that area. CNA also stated she had been trained to report suspected abuse so it could be investigated. In an interview on 6/11/14 at 12:15 p.m., CNA A stated that even if staff followed the chain of command nothing gets done. CNA A stated that CNA B had told CNA A that LVN A was reported by CNA B because LVN A was very verbally abusive towards residents. CNA A said alleged verbal abuse was reported to the DON, but nothing was done about it. CNA A stated one time Resident #3 was in the dining room, LVN A was giving Resident #3 a protein shake, when Resident #3 would not drink the shake, LVN A grabbed Resident #3's face and opened her mouth and told Resident #3 to drink her shake because she did not have time for that. CNA A did not report it to the Administrator because CNA B had just reported LVN A for being rude and nothing was done about it. CNA A did not indicate that she removed Resident #3 from harm during witnessed abuse. Record review of CNA A's witness statement obtained by the surveyors, dated 6/13/14, indicated that CNA A had witnessed many times LVN A be verbally and physically abusive towards Resident #3. Her statement indicated that during breakfast times, when LVN A was passing out her morning meds, she would approach Resident #3 and say, "Okay, it's time for you to take your drink and I don't want any bullshit from you because I'm not in the mood." CNA A also wrote that while LVN A would be forcing Resident #3 to drink, the drink would run down the side of Resident #3's mouth. CNA A wrote there had been times that Resident #3 would start coughing because of the liquid being forced and LVN A not giving Resident #3 time to swallow. In an interview on 6/11/14 at 1:00 p.m., CNA B stated in February or March 2014 Resident #15 was in the hallway, acting out, "throwing a fit." CNA B stated LVN A got in front of Resident #15 and pressed down on his shoulder by pinching Resident #15's shoulder down, and then LVN A told Resident #15 "she was not going to put up with it today." CNA B stated all of this had occurred before the administrator had arrived to work. When the Administrator arrived to the facility the incident was reported by CNA B to the Administrator. CNA B said after the administrator had spoken to LVN A, LVN A approached CNA B and asked her whether she had "turned her in for anything". CNA B said she did not know whether anything had been done about it. CNA B said she had witnessed LVN A being rude to other residents, but she could not remember what was said exactly. In a second interview on 6/11/14 at 2:51 p.m., CNA B stated she reported the incident with Resident #15 and LVN A to the Administrator the morning that it occurred. CNA B stated she was not asked to write a statement. CNA B stated she remembered another incident involving LVN A. CNA B stated when Resident #16 lived on the east side (where LVN A usually worked), Resident #16 had a tendency to try to get out of bed after being put in bed. CNA B said she would report it to LVN A, who then would go into Resident #16's room and push her back down against the bed and tell Resident #16 she did not have time for that. CNA B stated she verbally report it this incident to the former Administrator. CNA B did not indicate that she removed Resident #16 from harm during witnessed abuse. In an interview on 6/11/14 at 1:20 p.m., CNA C stated every morning during breakfast times LVN A grabs Resident #3's face by grabbing her cheeks, and pushes her forehead back, and shoves with a wooden spoon, the crushed medicine mixed with pudding, into Resident #3's mouth. CNA C stated she had also witnessed LVN A give Resident #3 her milkshakes in the same manner. CNA C stated when Resident #16 was living on the east side (where LVN A usually worked), Resident #16 would try to get out of bed, LVN A would push Resident #16's forehead and tell her to lie down. CNA C said this incident was reported to the former ADON, who no longer worked at the facility. CNA C stated they had quit reporting LVN A because nothing was done about it. CNA C did not indicate that she removed Resident #3 and #16 from harm during the witnessed abuse. In an interview on 6/16/14 at 1:00 p.m., CNA M stated former ADON had quit working for the facility one week before he was terminated. CNA M stated he was terminated by the facility on 6/09/14. Record review of CNA C's witness statement obtained by the surveyors, dated 6/13/14, indicated that CNA C had witnessed LVN A forcing medicine into Resident #3's mouth while grabbing her by her cheeks ...CNA C also wrote when Resident #16 would try to get out of bed, LVN A would shove Resident #16 down with her hands and say, "I don't have time for this[***]!! Go to sleep" ...CNA C wrote that she reported these things to the former ADON, and the current DON, whom would always say, "okay we will take care of it," and nothing would get done. In an interview on 6/11/14 at 3:56 p.m., the Administrator stated when verbal reports of abuse are made by staff, the allegations are handled immediately. She said the facility takes statements from the reporters and give the alleged perpetrator an opportunity to write a statement. The Administrator said, she then suspends the alleged perpetrator until the investigation was finished. In an interview on 6/12/14 at 2:50 p.m., LVN A stated she had never been talked to or been reported for being abusive towards residents. LVN A said whenever she is giving medication, she takes her time with her residents. She said that she gives Resident #3 her Glucerna in the morning and that Resident #3 requires her assistance. LVN A states she assist Resident #3 with drinking her Glucerna by placing her hand over Resident #3's hand while Resident #3 holds her own cup. She said she might sometimes put her hand behind Resident #3's head and tilt her head a little bit, but that she is always gentle. LVN A said she had never pushed or made any resident stay in bed, or mishandle or been verbally abusive against any residents. LVN A said when CNAs report to her that residents are acting out in the hallway or if the residents try to get out of bed; she goes and assesses the residents to see what is wrong and tries to investigate the underlining reason behind the behavior. LVN A denied ever grabbing Resident #3's face, making her drink the shakes, or telling Resident #3 she did not have time for her. LVN A denied ever pinching/pushing Resident #15 down while in the hallway while Resident #15 was in his wheelchair due to behaviors. LVN A denies ever pushing Resident #16 against her bed or pushing her forehead because Resident #16 was trying to get out of bed. LVN A said she always took time with her residents. In an interview on 6/13/14 at 9:55 a.m., the Administrator stated she was the Abuse Coordinator. The Administrator stated LVN A had not been reported for grabbing Resident #3's face while LVN A was giving her shakes or administering medications in the mornings. The Administrator stated LVN A had not been reported for pushing Resident #16 down in the bed when she was trying to get out of bed. The Administrator stated a CNA reported LVN A for pushing too hard on Resident #15's shoulder while Resident #15 was in the hallway. The Administrator said she investigated the incident and took statements, and after the investigation was completed, it was determined by the facility that LVN A was "just resting" her hand on Resident #15's shoulder. The Administrator also stated she had not reported the incident to the state. She said normally when allegations are made against someone; she puts that investigation in the staff ' s personnel file. The Administrator said she would have to look through her stuff to see where that investigation was at. In an interview on 6/13/14 at 10:10 a.m., the Administrator handed LVN A's personnel file to surveyor and stated there was not any documentation in LVN A's personnel file concerning Resident #15's incident, but that there should be some documentation about it in LVN A's file. The Administrator said she did not know why her staff was not reporting abuse to her. In an interview on 6/13/14 at 10:50 a.m., the Administrator said she did not do a written investigation, but completed a verbal investigation regarding CNA A's report of LVN A pushing and pinching downward on Resident #15's shoulder. The Administrator then said, "My bad." In an interview on 6/17/14 at 12:00 p.m., the DON stated no staff had ever reported LVN A for abuse to her. Record review, on 6/12/14, of LVN A personnel files did not revealed any documentation related to LVN A being investigated or counseled over any type of abuse. Record review of Grievance Logs from 9/2013-6/2014 revealed no documentation concerning Resident #15 and LVN A. This was determined to be Immediate Jeopardy (IJ) on 06/13/14 at 2:00 PM and the Administrator, DON, RN Consultant, and RN Regulatory Compliance Consultant were notified. The following Plan of Abatement was submitted by the facility on 06/19/14 at 9:30 AM: Failure to report and investigate: 1. The identified allegation SR14- 2 was reported on 06/13/14, reported to the Texas Department of Aging and Disability on 06/13/14. Regional Vice President will oversee any investigative process in the absence of the Administrator for a completed and thorough investigation until conclusion effective 06/13/14. The alleged perpetrator was suspended pending investigation on 06/13/14. The investigation of this allegation of abuse did include interview of staff who have worked with the alleged perpetrator around the time the resident reports the incident occurred. The Social Worker has interviewed alert and oriented residents who reside on any unit the alleged perpetrator has worked 06/14/14. 2. Any allegation of abuse, neglect, exploitation or improper physical restraint of a resident will be called to the Texas Department of Aging and Disability. All allegations of abuse, neglect, exploitation of a resident have been reported to the Texas Department of Aging and Disability within 24 hours of identification, thoroughly investigated, documented, and the results of that investigation reported in five working days to the Texas Department of Aging and Disability by the Administrator and/or Regional Vice President. The Social Worker has completed an interview with all interviewable current in-house residents regarding any concerns the resident may have on abuse, neglect, exploitation of property 06/14/14. The Regional Vice President and Clinical Service Director have completed interviews with current employees regarding any concerns they may have focusing on abuse, neglect or exploitation of property 06/16/14. If during the initial interview process the Administrator becomes aware of any resident concerns or employee concerns regarding abuse, neglect or exploitation of goods, the issue will be documented and reported to the Texas Department of Aging and Disability within 24 hours, and immediate investigation will ensue. This investigation will be submitted to the Texas Department of Aging and Disability in five working days of reporting. If during the initial interview process the Administrator becomes aware of resident concerns that are not state reportable, a grievance form will be completed, and an investigation into the resident's concerns will ensue. Outcomes of the investigation into the grievance and the resolution will be discussed with the resident. 3. The Administrator and Director of Nursing have been reeducated by the Clinical Service Director that all allegations of abuse, neglect, exploitation of a resident have been reported to the Texas Department of Aging and Disability within 24 hours of identification, thoroughly investigated, documented, and the results of that investigation reported in five working days to the Texas Department of Aging and Disability by the Administrator and/or regional vice resident 06/10/14. The Administrator has been suspended pending investigation 06/13/14. The Administrator was brought back 06/16/14 with reeducation on confidentiality, sensitivity training, and final written counseling. The Clinical Services Director and a fundamental clinical operational services regulatory team member have reeducated all staff including housekeeping and therapy staff on immediate reporting of any suspected abuse and neglect of a resident to the abuse coordinator initiated on 06/13/14, and will continue until 100% compliance achieved. Facility staff has been reeducated that the facility In-Touch Line is a communication tool which provides all staff/patients/residents/family/friends etc., with an outlet to express any complaints or concerns they may have to an impartial source. Reports can be made by calling the In-Touch Line at [PHONE NUMBER] or the Texas Department of Aging and Disability. A representative of the Fundamental Clinical Operational Clinical Services Department will be present onsite daily until all aspects of this abatement plan have been fully implemented and sustained compliance as evidenced by ongoing audits of incident reports, grievances, and resident interviews. In progress. The Regional Vice President in the absence of the Administrator will review all allegations of abuse and grievances for appropriate follow up per facility policy and procedure. 4. The Quality Assurance Performance Improvement Committee will review allegations of abuse and grievances monthly times three months and then quarterly until the quality assurance performance improvement committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. Record review of Facility's In-Service Training Report, dated 6/13/14, revealed RN VPRC had in-serviced facility staff on Abuse/Neglect to address the IJ in the area of failure to report and investigate. The in-service instructed staff that "All incidents must be reported, if you witnessed something you need to report to your immediate supervisor, if unable to tell immediate supervisor then go through the chain of command ... All identified issues is to be reported immediately within a 24 hour timeframe ...All identified issues must be thoroughly investigated with documentation to support findings ...Always remember an allegation is reported first and then thoroughly investigated and followed up with a 5 day follow up report. The abuse coordinator is the Administrator..." Sign in sheets were provided to show staff's attendance at the in-service. Interviews with facility staff between 06/13/14-06/19/14 revealed staff was able to identify the following: Different types of abuse The facility ' s Abuse Coordinator, Appropriate methods for ensuring resident safety and reporting abuse In an interview on 06/19/18 at 9:45 a.m. the Social Worker said that she has done resident interviews with those residents who are interviewable regarding abuse. The Social Worker said that any concerns revealed were reported to the Administrator. She said that she had not conducted satisfaction interviews with residents prior to the identification of the IJ. She said that this was part of the plan to help identify and prevent future abuse. Record review of Facility's In-Service Training Report, dated 6/13/14, revealed RN VPRC had in-serviced facility staff on Abuse/Neglect to address the IJ in the area of failure to report and investigate. The in-service instructed staff that "All incidents must be reported, if you witnessed something you need to report to your immediate supervisor, if unable to tell immediate supervisor then go through the chain of command ... All identified issues is to be reported immediately within a 24 hour timeframe ...All identified issues must be thoroughly investigated with documentation to support findings ...Always remember an allegation is reported first and then thoroughly investigated and followed up with a 5 day follow up report. The abuse coordinator is the Administrator..." Sign in sheets were provided to show staff's attendance at the in-service. Interviews with two CNAs on 06/15/14 revealed they had been re-inserviced on Abuse and Neglect. While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of potential for more than minimal harm and scope of "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. Record review of the facility's Form CMS-802, undated, provided by the facility upon entrance 6/09/14, indicated 71 residents resided in this facility.

Based on observation, interview and record review, the facility's Administrator, the DON, and the ADON failed to use the facility's resources effectively and efficiently to maintain the highest practicable physical well-being for five (Resident #1, #3, # 15, # 13, and #16) of seventeen residents reviewed for quality of care, assessments, abuse, and notification of changes. A) The Administrator failed to implement the facility's Abuse Policy when the Administrator failed to conduct a thorough investigation of allegations the Resident #15 was being physically abused by LVN A. B) The Administrator failed to ensure a functioning system was in place to protect residents from abuse and neglect. Two CNA's failed to report abuse of Resident #3 and #16 because of their belief that the Administrator would not take action to investigate the allegations. C) The Administrator, the DON, and ADON failed to ensure staff was trained in the proper techniques of a mechanical lift. The failure resulted in a mechanical lift tipping over during a transfer of Resident #1, and Resident # 1 sustaining significant skin tears covering an area from the middle of her left forearm to the middle of her left bicep and requiring wound care not available in the facility. D) The ADON and DON failed to monitor nursing staff to ensure appropriate assessments of Resident # 1 and #13 when they were experiencing a pain and change in condition. E) The DON and ADON failed to ensure nursing staff provided appropriate wound care, to follow treatment orders for wounds, and to provide physician preferred methods of treatment. The Administrator and DON also failed to ensure a sufficent amount of wound care supply was available to staff. F) The DON and the ADON also failed to ensure staff provided notification to Resident #13's physician when they were unable to obtain a UA from the resident or when the resident experienced a change in condition. On 06/10/14 an Immediate Jeopardy (IJ) was identified. On 06/13/14 additional IJs were identified . While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of actual harm at a pattern, because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 71 residents at risk for accident related injuries, abuse, not being assessed for a change in condition, and for the residents' physicians not receiving an accurate report of the residents' status, which could result in a resident's injury, decline in their condition, the need for hospitalization , or death. The findings included: In an interview on 06/17/14 at 12:20 PM the Administrator stated the Immediate Jeopardy identified in the area of abuse was due to her failure to report an incident involving allegations of abuse of Resident #15 by LVN A. The Administrator stated she did not document the investigation that she performed which included speaking with the CNA who made the allegations, the alleged perpetrator, and the resident. The Administrator stated that in regards to the incident involving Resident # 1 the injury the resident sustained [REDACTED]. In an interview on 06/17/14 at 12:00 PM the DON stated the failures identified were a result of a system failure. The DON stated the staff do not follow policies and procedures. The DON stated the staff's inabiltiy to obtain a UA from Resident #13 should have been reported to the physician, the family, and her. The DON stated that staff should have also notified Resident #13's physician when she experienced a change in condition. The DON stated she believes she conducted an appropriate investigation in to the incident involving Resident #1, but now realizes she should have reported the incident since facility equipment was involved. A. ABUSE Resident #3 Record review of Resident #3's Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 3/17/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) could not be conducted because Resident #1 was rarely/never understood. Under C1000 Cognitive Skills for Daily Decision Making revealed that Resident #3 had scored a "3", indicating her cognition was severely impaired with making decision regarding task of daily life. Section G: Activities of Daily Living (ADL) Assistance, G0110 indicated Resident #3 was totally dependent with the assistance of one staff with eating/drinking. In an observation on 6/13/14 at 1:20 p.m., revealed Resident #3 lying in bed with head of bed elevated at 15 degrees. Resident #3 was asked her name or how she was doing by surveyor, Resident #3 would just look at her television and would not acknowledged surveyor was present in the room. No obvious injuries or suspicious bruising was noted on body. Resident #3 appeared well groomed. Resident #15 Record review of Resident #15's Admission Record Sheet, undated, revealed a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 5/02/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) score as "0", indicating Resident #15's cognition was not intact. Section E: Behavior reflected Resident #15 did not exhibit physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others. Section G: Functional Status indicated Resident #15 required extensive assistance of one person with bed mobility, and extensive assistance of two or more person physical assistance for transfers. Resident #16 Record review of Resident #16's Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 4/17/14, reflected Resident #16's Brief Interview for Mental Status (BIMS) score as "99", indicating Resident #16 was unable to complete interview. Under C1000 Cognitive Skills for Daily Decision Making revealed that Resident #16 had scored a "3" , indicating her cognition was severely impaired with making decision regarding task of daily life. Section G Functional Status indicated Resident #16 required extensive assistance of two or more person physical assistance for bed mobility and transfers. In an observation on 6/19/14 at 9:43 a.m., revealed Resident #16 was sitting up in her wheelchair in the dining room in the locked unit. Resident #16 did not know her name or where she was at. All Resident #16 would say was that "it's kind of cold". A CNA brought Resident #16 a blanket and covered her legs. No obvious bruising or suspicious injuries were noted on Resident #16. Interviews: In an interview on 6/11/14 at 12:08 p.m., CNA A stated that if she saw a resident being abused by another staff member, she was trained to report it immediately and protect the resident by removing resident from that area. CNA also stated she had been trained to report suspected abuse so it could be investigated. In an interview on 6/11/14 at 12:15 p.m., CNA A stated that even if staff followed the chain of command nothing gets done. CNA A stated that CNA B had told CNA A that LVN A was reported by CNA B because LVN A was very verbally abusive towards residents. CNA A said alleged verbal abuse was reported to the DON, but nothing was done about it. CNA A stated one time Resident #3 was in the dining room, LVN A was giving Resident #3 a protein shake, when Resident #3 would not drink the shake, LVN A grabbed Resident #3's face and opened her mouth and told Resident #3 to drink her shake because she did not have time for that. CNA A did not report it to the Administrator because CNA B had just reported LVN A for being rude and nothing was done about it. CNA A did not indicate that she removed Resident #3 from harm during witnessed abuse. Record review of CNA A's witness statement obtained by the surveyors, dated 6/13/14, indicated that CNA A had witnessed many times LVN A be verbally and physically abusive towards Resident #3. Her statement indicated that during breakfast times, when LVN A was passing out her morning meds, she would approach Resident #3 and say, " Okay, it's time for you to take your drink and I don't want any bullshit from you because I'm not in the mood." CNA A also wrote that while LVN A would be forcing Resident #3 to drink, the drink would run down the side of Resident #3's mouth. CNA A wrote there had been times that Resident #3 would start coughing because of the liquid being forced and LVN A not giving Resident #3 time to swallow. In an interview on 6/11/14 at 1:00 p.m., CNA B stated in February or March 2014 Resident #15 was in the hallway, acting out, "throwing a fit." CNA B stated LVN A got in front of Resident #15 and pressed down on his shoulder by pinching Resident #15's shoulder down, and then LVN A told Resident #15 "she was not going to put up with it today." CNA B stated all of this had occurred before the administrator had arrived to work. When the Administrator arrived to the facility the incident was reported by CNA B to the Administrator. CNA B said after the administrator had spoken to LVN A, LVN A approached CNA B and asked her whether she had "turned her in for anything". CNA B said she did not know whether anything had been done about it. CNA B said she had witnessed LVN A being rude to other residents, but she could not remember what was said exactly. In a second interview on 6/11/14 at 2:51 p.m., CNA B stated she reported the incident with Resident #15 and LVN A to the Administrator the morning that it occurred. CNA B stated she was not asked to write a statement. CNA B stated she remembered another incident involving LVN A. CNA B stated when Resident #16 lived on the east side (where LVN A usually worked), Resident #16 had a tendency to try to get out of bed after being put in bed. CNA B said she would report it to LVN A, who then would go into Resident #16's room and push her back down against the bed and tell Resident #16 she did not have time for that. CNA B stated she verbally report it this incident to the former Administrator. CNA B did not indicate that she removed Resident #16 from harm during witnessed abuse. In an interview on 6/11/14 at 1:20 p.m., CNA C stated every morning during breakfast times LVN A grabs Resident #3's face by grabbing her cheeks, and pushes her forehead back, and shoves with a wooden spoon, the crushed medicine mixed with pudding, into Resident #3's mouth. CNA C stated she had also witnessed LVN A give Resident #3 her milkshakes in the same manner. CNA C stated when Resident #16 was living on the east side (where LVN A usually worked), Resident #16 would try to get out of bed, LVN A would push Resident #16's forehead and tell her to lie down. CNA C said this incident was reported to the former ADON, who no longer worked at the facility. CNA C stated they had quit reporting LVN A because nothing was done about it. CNA C did not indicate that she removed Resident #3 and #16 from harm during the witnessed abuse. In an interview on 6/16/14 at 1:00 p.m., CNA M stated former ADON had quit working for the facility one week before he was terminated. CNA M stated he was terminated by the facility on 6/09/14. Record review of CNA C's witness statement obtained by the surveyors, dated 6/13/14, indicated that CNA C had witnessed LVN A forcing medicine into Resident #3's mouth while grabbing her by her cheeks ...CNA C also wrote when Resident #16 would try to get out of bed, LVN A would shove Resident #16 down with her hands and say, "I don't have time for this[***]!! Go to sleep" ...CNA C wrote that she reported these things to the former ADON, and the current DON, whom would always say, "okay we will take care of it," and nothing would get done. In an interview on 6/11/14 at 3:56 p.m., the Administrator stated when verbal reports of abuse are made by staff, the allegations are handled immediately. She said the facility takes statements from the reporters and give the alleged perpetrator an opportunity to write a statement. The Administrator said, she then suspends the alleged perpetrator until the investigation was finished. In an interview on 6/12/14 at 2:50 p.m., LVN A stated she had never been talked to or been reported for being abusive towards residents. LVN A said whenever she is giving medication, she takes her time with her residents. She said that she gives Resident #3 her Glucerna in the morning and that Resident #3 requires her assistance. LVN A states she assist Resident #3 with drinking her Glucerna by placing her hand over Resident #3's hand while Resident #3 holds her own cup. She said she might sometimes put her hand behind Resident #3's head and tilt her head a little bit, but that she is always gentle. LVN A said she had never pushed or made any resident stay in bed, or mishandle or been verbally abusive against any residents. LVN A said when CNAs report to her that residents are acting out in the hallway or if the residents try to get out of bed; she goes and assesses the residents to see what is wrong and tries to investigate the underlining reason behind the behavior. LVN A denied ever grabbing Resident #3's face, making her drink the shakes, or telling Resident #3 she did not have time for her. LVN A denied ever pinching/pushing Resident #15 down while in the hallway while Resident #15 was in his wheelchair due to behaviors. LVN A denies ever pushing Resident #16 against her bed or pushing her forehead because Resident #16 was trying to get out of bed. LVN A said she always took time with her residents. In an interview on 6/13/14 at 9:55 a.m., the Administrator stated she was the Abuse Coordinator. The Administrator stated LVN A had not been reported for grabbing Resident #3's face while LVN A was giving her shakes or administering medications in the mornings. The Administrator stated LVN A had not been reported for pushing Resident #16 down in the bed when she was trying to get out of bed. The Administrator stated a CNA reported LVN A for pushing too hard on Resident #15's shoulder while Resident #15 was in the hallway. The Administrator said she investigated the incident and took statements, and after the investigation was completed, it was determined by the facility that LVN A was "just resting" her hand on Resident #15's shoulder. The Administrator also stated she had not reported the incident to the state. She said normally when allegations are made against someone; she puts that investigation in the staff's personnel file. The Administrator said she would have to look through her stuff to see where that investigation was at. In an interview on 6/13/14 at 10:10 a.m., the Administrator handed LVN A's personnel file to surveyor and stated there was not any documentation in LVN A's personnel file concerning Resident #15's incident, but that there should be some documentation about it in LVN A's file. The Administrator said she did not know why her staff was not reporting abuse to her. In an interview on 6/13/14 at 10:50 a.m., the Administrator said she did not do a written investigation, but completed a verbal investigation regarding CNA A's report of LVN A pushing and pinching downward on Resident #15's shoulder. The Administrator then said, "My bad." In an interview on 6/17/14 at 12:00 p.m., the DON stated no staff had ever reported LVN A for abuse to her. Record review on 6/12/14 of LVN A personnel files did not revealed any documentation related to LVN A being investigated or counseled over any type of abuse. Record review of Grievance Logs from September 2013-June 2013 revealed no documentation concerning Resident #15 and LVN A. Record review of the Facility's Leadership Policies and Procedures: Abuse, Neglect and Misappropriation, revised on 05/01/13, revealed "The facility's Leadership prohibits neglect, mental or physical abuse ... The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and/or funds. The facility's Leadership will provide notification to the proper authorities . . . The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident . . ." According to the facility's abuse policy "staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types of abuse include but are not limited to physical assault/abuse . . . mental abuse . . . verbal abuse . . . neglect . . . All alleged violations concerns abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator . . . and other enforcement agencies according to state law including the State Survey and Certification Agency . . . The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken . . . The investigation may include but is not limited to the following: Identification and removal of the alleged perpetrators . . .Written summaries of interviews with individuals having firsthand knowledge of the incident . . . Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer . . .In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process . . . Guidelines for Investigation: Immediately assess the resident/patient at the time of discovery of alleged abuse. Document assessment in the medical record. Maintain the resident's/patient's protection during the investigation . . . Protection: During the investigation, the facility protect the patient/resident, as appropriate, including but not limited to the following: Removal of the alleged abuser from the patient/resident care setting. Enforcing a zero tolerance standard for retaliation against the alleged victim." B. ACCIDENTS AND SUPERIVISION Resident # 1 Record review of Resident #1 admission record, undated, revealed an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS dated [DATE] revealed she was limited to making concrete requests, could respond adequately to simple, direct communication only, was severely cognitively impaired, had no behaviors, was totally dependent on two persons for transfers, required extensive assistance of two persons for dressing, toileting, and bathing, required extensive of one person for eating and personal hygiene, was incontinent of bowel and bladder. A staff assessment of pain indicated she exhibited non-verbal sounds (moaned, groaned) and had facial expression (grimaces, wrinkled forehead, furrowed brow) daily. Record review of Resident #1 ' s care plan, dated 5/26/17, revealed the resident had been identified on 03/18/14 as having problems in the area of ADL Functional/Rehabilitation Potential. The care plan stated the resident required assistance with ADL. The goal was for Resident #1 to " maintain a sense of dignity by being clean, dry, odor free and well groomed over the next 90 days " . The approach to transfers was " two person assist " via " Hoyer lift " . Record review of Resident #1's "Nurse's Notes" dated 06/07/14 at 6:30 a.m. revealed, "Two CNA's (CNA G and CNA H) were transferring resident from bed to geri-chair using hoyer (mechanical) lift. Resident was properly placed in sling, but when resident became restless she shifted and the mechanical lift flipped over to the side. One of the CNA's stopped resident from hitting her head, and nurse was called to room at 5:45 a.m. Head to toe assessment performed. Resident has several skin tears from the bicep of her left arm down to the forearm of her left arm. Skin flaps were intact, they were cleaned and stretched back out and covered with a dressing. Resident also has some bruising to left leg. Resident was given medication for pain. Vital signs - 147/83, 98.1 degree temperature, 93 pulse, 22 respirations and 92% (oxygen saturation). Resident did not hit head according to CNAs. Dr... was informed ...and stated to keep resident under observation and daughter was called as well. Will continue to monitor. In an interview on 06/10/14 at 4:30 p.m. CNA H said that on 06/07/14 she and CNA G were attempting to transfer Resident #1 from her bed to her geri-chair when Resident #1 and the lift fell over. CNA H said that she was steering the mechanical lift and CNA G was on the other side with Resident #1. CNA H said that she did not know if the mechanical lift legs were in the open or closed position when the lift fell over with Resident #1 because the geri-chair was obstructing her view. She said that Resident #1 was in the sling and was hovering over the geri-chair when the lift and Resident #1 fell over to the left. She said that another CNA had warned her that the legs on the lift sometime closed on their own without warning. She said that she had not reported this to anyone. In an interview and observation on 06/10/14 at 4:50 p.m. CNA G said that on 06/07/14 she and CNA H were attempting to transfer Resident #1 from her bed to her geri-chair. CNA G said that CNA H pushed the mechanical lift under Resident #1's bed and then each of them placed the loops of the slings onto the lift hooks. She said that CNA H was steering the lift and then she demonstrated two consecutive times how the transfer occurred. She said that CNA H put the legs of the mechanical lift underneath Resident #1's bed with the legs together, the sling was attached to the lift, CNA H backed the lift away from the bed, opened the legs wide, moved the lift to the geri-chair, and then closed the legs of the lift to place underneath the geri-chair. CNA G said at that time Resident #1 shifted in the sling and the lift and Resident #1 fell to the left and Resident #1 landed on the floor on her right side with the sling still in place and her head on CNA G ' s lap. CNA G said that it happened so fast and that she tried to catch Resident #1's head so that it would not hit the floor. In an interview on 06/10/14 at 2:20 p.m. LVN C said that on 06/07/14 at about 5:45 a.m. she was at the nursing station when she heard a loud crash. LVN C said that she entered Resident #1's room and saw the mechanical lift flipped over, Resident #1 was on the floor still in the sling lying on her right side. She said that Resident #1 had her head on CNA G's lap She said that she unhooked the sling from the mechanical lift and laid Resident #1 on her back to assess her. She said that she saw bleeding and discoloration on her left arm. She described the wounds as extending from above the elbow down to her forearm. She said that she did not measure the wounds. Record review of LVN C's "Witness Statement" dated 06/10/14 revealed, "I, LVN C, approximately at 5:45 a.m. on 06/07/14 was standing at the medication cart when I heard a loud crash. I ran in the direction of the noise and when I reached room , I saw the resident had been dropped out of the hoyer (mechanical) lift, and CNA H was yelling for the nurse. The other CNA had her right leg underneath the residents head ...When I touched the resident she immediately began to moan ...I then called Dr. and Dr. was on call and I described that the resident had been dropped out of the hoyer (mechanical) lift and had 3 skin tears to left arm, and bruising to left lower extremity area. I explained that she had diabetes type 2, was on [MEDICATION NAME], and was a double lower extremity [MEDICAL CONDITION] ...I then called the daughter and told her that her mom had been dropped out of the hoyer (mechanical) lift and had skin tears on her left arm from her bicep to the bottom of her forearm. I then called DON, I left a message when I did not receive an answer. I then did my documentation and told the oncoming nurse what I had done and that the DON had not answered that I had left a message." In an interview on 06/09/14 at 3:50 p.m., the DON stated the incident involving Resident #1 had occurred on 6/7/14 and through interviews she discovered two CNAs were transferring Resident #1 when the mechanical lift tipped over. The DON stated Resident #1 did not go to the emergency room after the fall. In an interview on 06/09/14 at 4:50 p.m. with the Administrator and the DON, the Administrator said the ADON was called in on Saturday because Resident #1 had fallen and had received a skin tear. The Administrator said the ADON had gone in and assessed the resident, but did not further assess the wound to left arm because Resident #1 already had bandages over the wound and the ADON was afraid to remove the dressing because Resident #1 was on [MEDICATION NAME]; the ADON was afraid the wound might start bleeding again. The DON said LVN C had left her a message about the incident on 06/07/14 around 6 a.m. The Administrator said the DON had called her, and she instructed the DON to call the Clinical Supervisor whom told the DON that skin tears were not reportable. The administrator stated what was concluded was that three people are needed to do transfers instead of two for Resident #1. Record review of the "Invacare Reliant 600 Manual/Electric Portable Patient Lift User Manual" dated 2011 provided by the facility as the user manual for the two mechanical lifts the facility provided for resident transfers revealed the following: Page 7 - Safety WARNING " ...Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient... Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted." Page 9 - Lifting the Patient " When using an adjustable base lift, the legs MUST be in the maximum Open/Locked position before lifting the patient. " Page 20 - Closing/Opening the Legs of the Base Assembly " The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to lose the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. " Page 21- Closing the Legs " 1. Stand at the rear of the patient lift and grasp the shifter handle with one hand and place the opposite hand on the steering handle of the mast for balance. The shifter handle MUST lock into its mounting slot to lock the legs in the full closed position. WARNING If the shifter handle is NOT positioned completely into its mounting slot, DO NOT use the patient lift until the shifter handle is properly seated and the legs of the patient lift are locked in place. Otherwise, injury and/or damage may occur. 2. Pull the shifter handle away from the patient lift and then to your left until it locks in the notch of the bracket. Page 21 - Opening the Legs " 1. Stand at the rear of the patient lift and grasp the shifter handle with one hand and place the opposite hand on the steering handle of the mast for balance. The shifter handle MUST lock into its mounting slot to lock the legs in the full closed position. " 2. Pull the shifter handle away from the patient lift and then to your right." Page 22 - Raising/Lowering a Manual/Hydraulic Lift WARNING " Invacare does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object." Page 29 - Attaching Slings to the Lift " 1. Attach the straps of the sling over hooks of the swivel bar. 2. Match the corresponding colors on each side of the sling for an even lift of the patient." In an interview on 06/10/14 at 5:20 p.m. the ADON said that she had investigated Resident #1's fall from the mechanical lift. The ADON said that she worked the day 06/07/14 that Resident #1 fell over with the mechanical lift. She said that she had done some mechanical lift in-services after the accident. She said that no proficiency skills have been done prior to the accident nor have they been done during orientation. She said that she had spoken to CNA H by phone and was told that the mechanical lift legs were together under the bed of Resident #1 and the legs were opened when she was moved away from bed toward the geri-chair. In an interview on 06/10/14 at 7:55 p.m. the DON said that the ADON had started the investigation regarding Resident #1's fall from the mechanical lift. She said that LVN C, CNA G, and CNA H had been interviewed. She said that the conclusion of the investigation currently was that Resident #1was too heavy and was moving around. She said that she had stopped her investigation because of the survey team. She said that she had not provided training or monitoring of staff regarding the use of the mechanical lifts. She said that she did not know if the ADON had provided training or monitoring of staff regarding the use of the mechanical lifts. She said that she had been the DON since 06/2013. She said she was responsible for monitoring and ensuring that staff was trained. She provided a form, "Staff Education/Orientation Policies and Procedures, Nursing Competency - Use of Mechanical Lifts" form dated 07/01/2013 and said had planned to use this form but had not yet. However, the DON said that the form did not exactly match the instructions related to their mechanical lift. Observation on 06/10/14 at 6:20 p.m. revealed CNA I and CNA J transferred Resident #11 from her wheelchair to her bed. CNA J pushed the mechanical lift toward Resident #11's wheelchair, opened the legs of the lift underneath the wheelchair, locked the two back wheels and attached the loops to the sling. The black loops of the sling were hooked onto the lift at Resident #11's legs and the green loops of the sling were hooked onto the lift at Resident #11's head. CNA J said that there were colored loops to attach the sling to the lift (red, green, blue, and black) but that it was difficult to distinguish between the colors because they had faded. CNA J using the remote control lifted Resident #11 from her wheelchair, unlocked the back two wheels, moved the lift (with legs wide open) underneath the bed. CNA J locked the two back wheel locks, lowered Resident #11 onto the bed, unhooked the loops from the lift, unlocked the two back wheel locks, and moved the lift out from under the bed. Page 22 - Raising/Lowering a Manual

Based on interview and record review, the facility failed to ensure allegations of abuse/neglect were investigated and reported to the State survey and certification agency for three of seventeen residents (Resident #3, #15, and #16) reviewed for incidents of abuse/neglect as evidenced by: a. The facility failed to investigate, protect, and report allegations of abuse, LVN A physically and verbally abused Resident #3, #15, and #16. b. CNA A, B, and C failed to report and protect Residents #3 and #16 from being abused by LVN A. On 06/13/14 IJ was identified. While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of a potential for more than minimal harm and scope of "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. This failure could affect all 71 residents residing in the facility by placing them at risk for abuse or neglect. The findings included: Resident #3 Record review of Resident #3's Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 3/17/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) could not be conducted because Resident #1 was rarely/never understood. Under C1000 Cognitive Skills for Daily Decision Making revealed that Resident #3 had scored a "3", indicating her cognition was severely impaired with making decision regarding task of daily life. Section G: Activities of Daily Living (ADL) Assistance, G0110 indicated Resident #3 was totally dependent with the assistance of one staff with eating/drinking. In an observation on 6/13/14 at 1:20 p.m., revealed Resident #3 lying in bed with head of bed elevated at 15 degrees. Resident #3 was asked her name or how she was doing by surveyor, Resident #3 would just look at her television and would not acknowledged surveyor was present in the room. No obvious injuries or suspicious bruising was noted on body. Resident #3 appeared well groomed. Resident #15 Record review of Resident #15's Admission Record Sheet, undated, revealed a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 5/02/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) score as "0", indicating Resident #15's cognition was not intact. Section E: Behavior reflected Resident #15 did not exhibit physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others. Section G: Functional Status indicated Resident #15 required extensive assistance of one person with bed mobility, and extensive assistance of two or more person physical assistance for transfers. Resident #16 Record review of Resident #16's Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 4/17/14, reflected Resident #16's Brief Interview for Mental Status (BIMS) score as "99", indicating Resident #16 was unable to complete interview. Under C1000 Cognitive Skills for Daily Decision Making revealed that Resident #16 had scored a "3" , indicating her cognition was severely impaired with making decision regarding task of daily life. Section G Functional Status indicated Resident #16 required extensive assistance of two or more person physical assistance for bed mobility and transfers. In an observation on 6/19/14 at 9:43 a.m., revealed Resident #16 sitting up in her wheelchair in the dining room in the locked unit. Resident #16 did not know her name or where she was at. All Resident #16 would say was that "it's kind of cold". A CNA brought Resident #16 a blanket and covered her legs. No obvious bruising or suspicious injuries were noted on Resident #16. Interviews: In an interview on 6/11/14 at 12:08 p.m., CNA A stated that if she saw a resident being abused by another staff member, she was trained to report it immediately and protect the resident by removing resident from that area. CNA also stated she had been trained to report suspected abuse so it could be investigated. In an interview on 6/11/14 at 12:15 p.m., CNA A stated that even if staff followed the chain of command nothing gets done. CNA A stated that CNA B had told CNA A that LVN A was reported by CNA B because LVN A was very verbally abusive towards residents. CNA A said alleged verbal abuse was reported to the DON, but nothing was done about it. CNA A stated one time Resident #3 was in the dining room, LVN A was giving Resident #3 a protein shake, when Resident #3 would not drink the shake, LVN A grabbed Resident #3's face and opened her mouth and told Resident #3 to drink her shake because she did not have time for that. CNA A did not report it to the Administrator because CNA B had just reported LVN A for being rude and nothing was done about it. CNA A did not indicate that she removed Resident #3 from harm during witnessed abuse. Record review of CNA A's witness statement obtained by the surveyors, dated 6/13/14, indicated that CNA A had witnessed many times LVN A be verbally and physically abusive towards Resident #3. Her statement indicated that during breakfast times, when LVN A was passing out her morning meds, she would approach Resident #3 and say, " Okay, it's time for you to take your drink and I don't want any bullshit from you because I'm not in the mood." CNA A also wrote that while LVN A would be forcing Resident #3 to drink, the drink would run down the side of Resident #3's mouth. CNA A wrote there had been times that Resident #3 would start coughing because of the liquid being forced and LVN A not giving Resident #3 time to swallow. In an interview on 6/11/14 at 1:00 p.m., CNA B stated in February or March 2014 Resident #15 was in the hallway, acting out, "throwing a fit." CNA B stated LVN A got in front of Resident #15 and pressed down on his shoulder by pinching Resident #15's shoulder down, and then LVN A told Resident #15 "she was not going to put up with it today." CNA B stated all of this had occurred before the administrator had arrived to work. When the Administrator arrived to the facility the incident was reported by CNA B to the Administrator. CNA B said after the administrator had spoken to LVN A, LVN A approached CNA B and asked her whether she had "turned her in for anything". CNA B said she did not know whether anything had been done about it. CNA B said she had witnessed LVN A being rude to other residents, but she could not remember what was said exactly. In a second interview on 6/11/14 at 2:51 p.m., CNA B stated she reported the incident with Resident #15 and LVN A to the Administrator the morning that it occurred. CNA B stated she was not asked to write a statement. CNA B stated she remembered another incident involving LVN A. CNA B stated when Resident #16 lived on the east side (where LVN A usually worked), Resident #16 had a tendency to try to get out of bed after being put in bed. CNA B said she would report it to LVN A, who then would go into Resident #16's room and push her back down against the bed and tell Resident #16 she did not have time for that. CNA B stated she verbally report it this incident to the former Administrator. CNA B did not indicate that she removed Resident #16 from harm during witnessed abuse. In an interview on 6/11/14 at 1:20 p.m., CNA C stated every morning during breakfast times LVN A grabs Resident #3's face by grabbing her cheeks, and pushes her forehead back, and shoves with a wooden spoon, the crushed medicine mixed with pudding, into Resident #3's mouth. CNA C stated she had also witnessed LVN A give Resident #3 her milkshakes in the same manner. CNA C stated when Resident #16 was living on the east side (where LVN A usually worked), Resident #16 would try to get out of bed, LVN A would push Resident #16's forehead and tell her to lie down. CNA C said this incident was reported to the former ADON, who no longer worked for the facility. CNA C stated they had quit reporting LVN A because nothing was done about it. CNA C did not indicate that she removed Resident #3 and #16 from harm during the witnessed abuse. In an interview on 6/16/14 at 1:00 p.m., CNA M stated former ADON had quit working for the facility one week before he was terminated. CNA M stated he was terminated by the facility on 6/09/14. Record review of CNA C's witness statement obtained by the surveyors, dated 6/13/14, indicated that CNA C had witnessed LVN A forcing medicine into Resident #3's mouth while grabbing her by her cheeks ...CNA C also wrote when Resident #16 would try to get out of bed, LVN A would shove Resident #16 down with her hands and say, "I don't have time for this[***]!! Go to sleep" ...CNA C also wrote that she reported these things to the former ADON, and the current DON, whom would always say, "okay we will take care of it," and nothing would get done. In an interview on 6/11/14 at 3:56 p.m., the Administrator stated when verbal reports of abuse are made by staff, the allegations are handled immediately. She said the facility takes statements from the reporters and give the alleged perpetrator an opportunity to write a statement. The Administrator said, she then suspends the alleged perpetrator until the investigation was finished. In an interview on 6/12/14 at 2:50 p.m., LVN A stated she had never been talked to or been reported for being abusive towards residents. LVN A said whenever she is giving medication, she takes her time with her residents. She said that she gives Resident #3 her Glucerna in the morning and that Resident #3 requires her assistance. LVN A states she assist Resident #3 with drinking her Glucerna by placing her hand over Resident #3's hand while Resident #3 holds her own cup. She said she might sometimes put her hand behind Resident #3's head and tilt her head a little bit, but that she is always gentle. LVN A said she had never pushed or made any resident stay in bed, or mishandle or been verbally abusive against any residents. LVN A said when CNAs report to her that residents are acting out in the hallway or if the residents try to get out of bed; she goes and assesses the residents to see what is wrong and tries to investigate the underlining reason behind the behavior. LVN A denied ever grabbing Resident #3's face, making her drink the shakes, or telling Resident #3 she did not have time for her. LVN A denied ever pinching/pushing Resident #15 down while in the hallway while Resident #15 was in his wheelchair due to behaviors. LVN A denies ever pushing Resident #16 against her bed or pushing her forehead because Resident #16 was trying to get out of bed. LVN A said she always took time with her residents. In an interview on 6/13/14 at 9:55 a.m., the Administrator stated she was the Abuse Coordinator. The Administrator stated LVN A had not been reported for grabbing Resident #3's face while LVN A was giving her shakes or administering medications in the mornings. The Administrator stated LVN A had not been reported for pushing Resident #16 down in the bed when she was trying to get out of bed. The Administrator stated a CNA reported LVN A for pushing too hard on Resident #15's shoulder while Resident #15 was in the hallway. The Administrator said she investigated the incident and took statements, and after the investigation was completed, it was determined by the facility that LVN A was "just resting" her hand on Resident #15's shoulder. The Administrator also stated she had not reported the incident to the state. She said normally when allegations are made against someone; she puts that investigation in the staff's personnel file. The Administrator said she would have to look through her stuff to see where that investigation was at. In an interview on 6/13/14 at 10:10 a.m., the Administrator handed LVN A's personnel file to surveyor and stated there was not any documentation in LVN A's personnel file concerning Resident #15's incident, but that there should be some documentation about it in LVN A's file. The Administrator said she did not know why her staff was not reporting abuse to her. In an interview on 6/13/14 at 10:50 a.m., the Administrator said she did not do a written investigation, but completed a verbal investigation regarding CNA A's report of LVN A pushing and pinching downward on Resident #15's shoulder. The Administrator then said, "My bad." In an interview on 6/17/14 at 12:00 p.m., the DON stated no staff had ever reported LVN A for abuse to her. Record review on 6/12/14 of LVN A personnel files did not revealed any documentation related to LVN A being investigated or counseled over any type of abuse. Record review of Grievance Logs from 9/2013-6/2014 revealed no documentation concerning Resident #15 and LVN A. Record review of the Facility's Leadership Policies and Procedures: Abuse, Neglect and Misappropriation, revised on 05/01/13, revealed "The facility's Leadership prohibits neglect, mental or physical abuse ... The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and/or funds. The facility's Leadership will provide notification to the proper authorities . . . The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident . . ." According to the facility's abuse policy "staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types of abuse include but are not limited to physical assault/abuse . . . mental abuse . . . verbal abuse . . . neglect . . . All alleged violations concerns abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator . . . and other enforcement agencies according to state law including the State Survey and Certification Agency . . . The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken . . . The investigation may include but is not limited to the following: Identification and removal of the alleged perpetrators . . .Written summaries of interviews with individuals having firsthand knowledge of the incident . . . Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer . . .In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process . . . Guidelines for Investigation: Immediately assess the resident/patient at the time of discovery of alleged abuse. Document assessment in the medical record. Maintain the resident's/patient's protection during the investigation . . . Protection: During the investigation, the facility protect the patient/resident, as appropriate, including but not limited to the following: Removal of the alleged abuser from the patient/resident care setting. Enforcing a zero tolerance standard for retaliation against the alleged victim." This was determined to be Immediate Jeopardy (IJ) on 06/13/14 at 2:00 PM and the Administrator, DON, RN Consultant, and RN Regulatory Compliance Consultant were notified. The following Plan of Abatement was submitted by the facility on 06/19/14 at 9:30 AM: Failure to report and investigate: 1. The identified allegation SR14- 2 was reported on 06/13/14, reported to the Texas Department of Aging and Disability on 06/13/14. Regional Vice President will oversee any investigative process in the absence of the Administrator for a completed and thorough investigation until conclusion effective 06/13/14. The alleged perpetrator was suspended pending investigation on 06/13/14. The investigation of this allegation of abuse did include interview of staff who have worked with the alleged perpetrator around the time the resident reports the incident occurred. The Social Worker, has interviewed alert and oriented residents who reside on any unit the alleged perpetrator has worked 06/14/14. 2. Any allegation of abuse, neglect, exploitation or improper physical restraint of a resident will be called to the Texas Department of Aging and Disability. All allegations of abuse, neglect, exploitation of a resident have been reported to the Texas Department of Aging and Disability within 24 hours of identification, thoroughly investigated, documented, and the results of that investigation reported in five working days to the Texas Department of Aging and Disability by the Administrator and/or Regional Vice President. The Social Worker has completed an interview with all interviewable current in-house residents regarding any concerns the resident may have on abuse, neglect, exploitation of property 06/14/14. The Regional Vice President and Clinical Service Director have completed interviews with current employees regarding any concerns they may have focusing on abuse, neglect or exploitation of property 06/16/14. If during the initial interview process the Administrator becomes aware of any resident concerns or employee concerns regarding abuse, neglect or exploitation of goods, the issue will be documented and reported to the Texas Department of Aging and Disability within 24 hours, and immediate investigation will ensue. This investigation will be submitted to the Texas Department of Aging and Disability in five working days of reporting. If during the initial interview process the Administrator becomes aware of resident concerns that are not state reportable, a grievance form will be completed, and an investigation into the resident's concerns will ensue. Outcomes of the investigation into the grievance and the resolution will be discussed with the resident. 3. The Administrator and Director of Nursing have been reeducated by the Clinical Service Director that all allegations of abuse, neglect, exploitation of a resident have been reported to the Texas Department of Aging and Disability within 24 hours of identification, thoroughly investigated, documented, and the results of that investigation reported in five working days to the Texas Department of Aging and Disability by the Administrator and/or regional vice resident 06/10/14. The Administrator has been suspended pending investigation 06/13/14. The Administrator was brought back 06/16/14 with reeducation on confidentiality, sensitivity training, and final written counseling. The Clinical Services Director and a fundamental clinical operational services regulatory team member have reeducated all staff including housekeeping and therapy staff on immediate reporting of any suspected abuse and neglect of a resident to the abuse coordinator initiated on 06/13/14, and will continue until 100% compliance achieved. Facility staff has been reeducated that the facility In-Touch Line is a communication tool which provides all staff/patients/residents/family/friends etc., with an outlet to express any complaints or concerns they may have to an impartial source. Reports can be made by calling the In-Touch Line at [PHONE NUMBER] or the Texas Department of Aging and Disability. A representative of the Fundamental Clinical Operational Clinical Services Department will be present onsite daily until all aspects of this abatement plan have been fully implemented and sustained compliance as evidenced by ongoing audits of incident reports, grievances, and resident interviews. In progress. The Regional Vice President in the absence of the Administrator will review all allegations of abuse and grievances for appropriate follow up per facility policy and procedure. 4. The Quality Assurance Performance Improvement Committee will review allegations of abuse and grievances monthly times three months and then quarterly until the quality assurance performance improvement committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. Record review of Facility's In-Service Training Report, dated 6/13/14, revealed RN VPRC had in-serviced facility staff on Abuse/Neglect to address the IJ in the area of failure to report and investigate. The in-service instructed staff that "All incidents must be reported, if you witnessed something you need to report to your immediate supervisor, if unable to tell immediate supervisor then go through the chain of command ... All identified issues is to be reported immediately within a 24 hour timeframe ...All identified issues must be thoroughly investigated with documentation to support findings ...Always remember an allegation is reported first and then thoroughly investigated and followed up with a 5 day follow up report. The abuse coordinator is the Administrator..." Sign in sheets were provided to show staff's attendance at the in-service. Interviews with facility staff between 06/13/14-06/19/14 revealed staff was able to identify the following: Different types of abuse The facility ' s Abuse Coordinator, Appropriate methods for ensuring resident safety and reporting abuse In an interview on 06/19/18 at 9:45 a.m. the Social Worker said that she has done resident interviews with those residents who are interviewable regarding abuse. The Social Worker said that any concerns revealed were reported to the Administrator. She said that she had not conducted satisfaction interviews with residents prior to the identification of the IJ. She said that this was part of the plan to help identify and prevent future abuse. Interviews with two CNAs on 06/15/14 revealed they had been re-inserviced on Abuse and Neglect. While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of potential for more than minimal harm and scope of "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. Record review of the facility's Form CMS-802, undated, provided by the facility upon entrance 6/09/14, indicated 71 residents resided in this facility.

Based on interview and record review, it was determined the facility failed to consult the resident's physician when the resident experienced a significant change in condition for one (Resident #13) of 17 residents reviewed for notification of changes in condition. A. Resident #13 became displaying signs of a change in condition at approximatley 1:00 PM on 06/07/14 and her physician was notified by fax. Resident # 13 became increasingly lethargic and had limited responsiveness which resulted in staff withholding liquids due to fears of aspiration and withholding medications due to Resident #13 being unable to stay awake long enough to swallow the medication. The doctor was not notified of these increasingly significant changes in condition until 7:00 AM 06/08/14 when Resident #13 was found to be unresponsive and was sent to the hospital via ambulance. B. . The physician order [REDACTED]. The resident was subsequently admitted to the local hospital on [DATE] and diagnosed with [REDACTED]. C. Resident # 13 began to complain of pain to her right ankle immediatley after her fall and displayed swelling and bruising of right her ankle within eight hours of the fall, but her physician was not notified of these changes until approximately 24 hours after the fall. D. Resident # 13 experienced a fall on 06/05/14 and her physician was not notified until four hours after the fall. On 06/13/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of "potential for more than minimal harm" and scope of "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 71 residents at risk for the residents' physicians not being notified of the resident's change in condition, which could result in a delay in treatment or [DIAGNOSES REDACTED]. The findings included: Resident #13 Record review of Resident #13's Admission Record Sheet, undated, revealed Resident #13 was a [AGE] year old female admitted to the facility initially on 08/02/213 and most recently on 02/18/14 and her [DIAGNOSES REDACTED]. Record review of Resident #13 ' s clinical record revealed the following nurses ' note: 06/05/14 4:15 AM CNA found resident lying in floor by bed. Unable to state what happen and if she hit her head. . .No injuries noted but stated right ankle hurt. Patient beared weight with transfer . . . Some [MEDICAL CONDITION] present to right ankle with no bruising. Unable to tell if [MEDICAL CONDITION] was present before fall. Up in wheelchair at desk . . . Elevated right foot and applied ice pack to ankle. Patient denied complaints of pain at present. Neurological checks begun. Notified daughter and asked she visit to determine possible injury to right ankle. Blood pressure 130/76, pulse 76, respirations 18, temperature 98. Signed by RN B. Interview with Resident #13's family member on 06/10/14 at 12:00 PM revealed he/she was notified by facility staff on 06/05/14 of Resident #13's fall. The family member stated he/she went to the facility the morning of 06/05/14 after being notified of the fall and was told by LVN A an x-ray would be performed on Resident #13's right ankle. The family member stated he/she went back to the facility the evening of 06/05/14 and found Resident #13 to be in alot of pain and was informed by RN B an x-ray had not been obtained or ordered. The family member stated RN B informed him/her morning shift staff would be notified to request an x-ray. The family member stated that he/she returned to the facility on the morning of 06/06/14 and was told by LVN B an x-ray was being requested due to Resident #13's right ankle being bruised. Resident #13's family member stated every time he/she observed Resident #13 at the facility on 06/05/14 and 06/06/14 the resident was in pain and no pain medications were administered to the resident. The family member stated on 06/07/14, the night before Resident #13 was admitted to the hospital, the resident seemed "spaced out" and would not eat or drink anything. The family member stated he/she reported to LVN C his/her concerns and was told Resident #13's physician, Physician A, had been notified and nursing staff were monitoring the resident to see if she improved and if the resident did not improve she would be sent to the hospital in the morning. Record review of Resident #13's clinical record revealed a lab report, dated 06/05/14, detailing results of a BMP (Basic Metabolic Panel). The report identified three lab values that were elevated: Potassium 5.3 (reference range 3.5-5.1), Chloride 110 (reference range 98-107), and Glucose 141 (reference range 65-105). The report also identified one area that was low: GFR 54 (reference range >60) The National Kidney Foundation identifies potassium as an "important mineral found throughout our bodies. Potassium is a substance that conducts electricity (called an electrolyte) and plays a very important role in keeping your heartbeat regular and your muscles working properly. When kidneys are healthy, they keep the right amount of potassium in your body. Potassium levels that are too high or too low can cause health problems. When kidneys are not working properly, they have trouble removing potassium from the body. Without the ability to remove excess potassium, levels can rise and lead to serious health problems." http://www.kidney.org/news/monthly/potassiumCKD.cfm?homestatic=PhosphorusInfographic The National Library of Medicine identified chloride as "a type of electrolyte. It works with other electrolytes such as potassium, sodium, and carbon [MEDICATION NAME] (CO2). These substances help keep the proper balance of body fluids and maintain the body's acid-base balance." http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm The National Library of Medicine identified Glomerular filtration rate (GFR) as "a test used to check how well the kidneys are working. Specifically, it estimates how much blood passes through the glomeruli each minute. Glomeruli are the tiny filters in the kidneys that filter waste from the blood. . . . Levels below 60 mL/min/1.73 m2 for 3 or more months are a sign of [MEDICAL CONDITION]. GFR result lower than 15 mL/min/1.73 m2 is a sign of kidney failure and requires immediate medical attention." http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Record Review of Resident #13's clinical record revealed a Resident Transfer Form, undated, which indicated Resident #13 was transferred to the local emergency room . The form revealed Resident #13 experienced a [MEDICAL CONDITION] Lower Extremity on 06/06/14 and was non-weight bearing. The form revealed Resident #13's had a blood pressure of 90/40 (systolic/diastolic), a temperature of 99.9, and an oxygen saturation level of 79%. Resident #13's clinical record also contained the following entries in the nurse's notes: 06/03/14 11:30 AM Vital signs 140/82 (blood pressure), 97.6 (temperature), 77 (pulse), 18 (respirations), Night nurse reports increased confusion in evening. Faxed Physician A to request for follow up UA (urine analysis) and C&S (blood test for protein levels). Signed by LVN B. 06/03/14 9:00 PM Resident has been non-compliant with care this evening. She refused her shower and refused to let CNA change her into pajamas. She became verbally and physically aggressive towards staff. She requested to get into bed but refused to under her blankets. Signed by LVN C. 06/03/14 Received fax with order to do UA with C&S and BMP (base metabolic panel), order written and lab faxed. Signed by LVN C 06/04/14 12:45 AM Lab here and resident refused to try to void in toilet in hat for UA. Signed by LVN C. 06/04/14 4:00 PM Physician A here to make rounds-medications changed. (resident's daughter) made aware. Signed by LVN A. 06/05/14 9:45 AM Resident complained of generalized discomfort but has ROM (range of motion). . . Resident has generalized [MEDICAL CONDITION] to bilateral lower feet, ankles, and legs, bruising starting to form to right ankle. Physician A notified of fall, no new orders received. Signed by LVN A. 06/05/14 11:00 PM Have attempted several times to obtain UA. Patient refusing to have straight catheter performed. When placed on bed side commode refuses to void then wets diaper. Daughter visited to assist staff. Patient refused her also. Patient complains of pain to right ankle. No [MEDICAL CONDITION] noted. Refusing to stand on right foot. Daughter requested x-ray be done tomorrow. Stated we would notify MD in AM. Ice pack applied for comfort. Patient has episodes of confusion. Signed by RN B. 06/06/14 5:30 AM Patient continues to refuse to use bed side commode or allow nurse to catheterize her for UA specimen. Will alert oncoming shift. Signed by RN B. 06/06/14 6:45 AM Resident right ankle is bruised and swollen. Resident could not bear weight on right foot. Notified Physician A and new order received to x-ray right ankle. Notified mobile x-ray and resident daughter. Signed by LVN B. 06/06/14 9:00 AM Mobile x-ray at facility. Signed by LVN B. 06/06/14 9:30 AM x-ray report received (indicating fracture of right ankle). Called Physician A cell phone and left voice mail, notified his office nurse via voice mail and faxed x-ray report to his office. Notified DON and residents daughter of x-ray results. Signed by LVN B 06/06/14 9:45 AM New orders received (from Physician A) 1) ortho referral today 2) non-weight bearing right ankle. 06/06/14 4:15 PM return from ortho appointment. New orders received. One [MEDICATION NAME] 5/325 by mouth every six hours PRN. RLE in splint, non-weight bearing right ankle, keep ankle elevated, keep splint dry, and follow up appointment in one week. Notified Physician A and resident's daughter. Signed by LVN B. 06/06/14 6:00 PM Resident alert and denies any pain at present. In bed with RLE elevated, splint in place, call light in reach. 06/07/14 2:50 AM Vital signs: 140/81, 97.9, 80, 18, neuro checks WNL. Splint intact to RLE. Resident is non-weight bearing on right leg. Hoyer Lift for transfers. Denies any pain or discomfort. 06/07/14 1:00 PM Complaints of pain to RLE. Resident unable to be assessed using 1-10 pain scale. Resident states "it hurts pretty bad." [MEDICATION NAME] 5/325 given. 06/07/14 3:30 PM Resident sleepy and hard to arouse. Vital signs: 127/51, 97.7, 80, 18. Blood sugar by Accu-Chek 205. Would open eyes and respond to physical stimuli. Daughter at bedside, aware. Daughter concerned that [MEDICATION NAME] (prescribed on 06/04/14) is too sedating for Resident. Faxed Physician A status update. Signed by LVN B. 06/07/14 10:00 PM Resident remains sleepy and difficult to arouse. Daughter tried to feed her supper without success. Hold all the Residents meds due to sleepiness. Vital signs: 130/62, 97.6, 78, 18. Resident does open her eyes but cannot stay awake long enough to give meds to. Daughter is aware. Resident does respond to physical stimuli. Will continue to monitor. Signed by LVN C. 06/08/14 7:00 AM Resident very lethargic and hard to arouse. Color pale. Vital signs: 99/60, temperature 99.9, 84, 18. SPO2 70% on room air. Raised head of bed and placed on oxygen at 3 liters via nasal cannula. Notified Physician A and received order to send to emergency room to evaluate and treat. Notified residents daughter and called 911. 06/08/14 7:15 AM EMS at facility and Resident transported to ER via ambulance with copies of face sheet, H&P, immunization record and transfer form. Signed by LVN B. Record review of Resident #13's clinical record revealed a final x-ray report from mobile imaging, dated 06/06/14, for Resident #13's right ankle that provided the following impression: mildly displaced bimalleolar [MEDICAL CONDITION] ankle. The American Academy of Orthopedic Surgeons identify an ankle fracture as when one or more of the bones that make up the ankle joint "are broken" . The Academy identify the bones of the ankle as the tibia (shinbone), fibula (smaller bone of the lower leg), and the talus (a small bone that sits between the heel bone and the tibia and fibula " . The Academy identifies a bimalleolar fracture as when the " tibia and fibula are broken ". http://orthoinfo.aaos.org/topic.cfm?topic=a In an interview on 06/12/14 at 2:52 RN B stated she began trying to obtain a UA from Resident #13 on the night of 06/04/14 while working as the charge nurse for the 6:00 PM to 6:00 AM shift. RN B stated she attempted to have the resident use the bedside commode and attempt to insert a straight catheter. RN B stated the resident refused to be catheterized. RN B stated she was passing medication around 4:00 AM on 06/05/14 when she was notified by the aide that Resident #13 was found lying next to her bed. RN B stated she assessed Resident #13 fully, including her right ankle. RN B denied observing any bruising on the resident's ankle and stated she could not determine if the ankle was swollen from the fall or from [MEDICAL CONDITION]. RN B states initially the resident complained about pain in her ankle, but she did not pinpoint where the pain was at when assessing the resident. RN B stated she applied ice to the resident's ankle and contacted the daughter to request the daughter come to the facility to help determine if there was injury to the ankle. RN B confirmed she did not contact the doctor regarding the resident's fall as she wanted to wait for the daughter's input. RN B stated when she compared Resident #13's ankle the right ankle looked slightly bigger, but she was not sure if that was due to a scar on the resident's ankle. RN B stated that the resident's right ankle just "looked different". RN B stated she elevated the resident foot and waited for the resident's daughter to arrive. RN B stated prior to the end of her shift the resident took the ice pack off her ankle, said it did not hurt anymore, and wheeled herself toward the dining room. RN B stated that she contacted the resident's daughter prior to the doctor because the daughter is very involved and the "whole scar thing threw her". RN B stated it is not normal procedure to wait for family member's input before contacting the doctor. RN B stated that she did not see the resident after the resident removed the ice pack and went toward the dining room. RN B stated she reported to LVN A, who was taking over as charge nurse, that Resident #13 was complaining of pain to her ankle and that the doctor had not been contacted. RN B stated that she explained to LVN A that she was waiting for the resident's daughter to come to the facility and that she had been unable to obtain a UA. RN B stated the night of 06/05/14 she continued to try to obtain the UA, but the resident refused. RN B stated the resident's daughter came to the facility around 11:00 PM and she tried to assist in obtaining the UA without success. RN B stated the resident complained of pain, but then went to sleep. RN B stated she assessed the resident's right ankle when she complained of pain, but she did not observe an swelling or bruising at that time. RN B stated she could not remember if LVN A had reported to her about bruising on the right ankle, but does remember LVN A stating the resident had not complained of pain so an x-ray had not been ordered. RN B stated the resident's daughter told her LVN A had said they would be doing an x-ray of her mother's ankle. RN B stated she could not remember if the resident's daughter requested an x-ray. RN B stated if she would rely more on her nurse's notes for an accurate account of events (nurse's notes indicate daughter requested an x-ray and RN B would let the day shift know of her request). RN B stated she did not know why she would have referred the daughter's request for an x-ray to the day shift and not just sent the fax in herself. RN B admitted that she only visually assessed the right ankle during her shift beginning on 06/05/14 and ending on 06/06/14 and never touched or palpated the right ankle. RN B stated on the morning of 06/06/14 the resident was up in her wheelchair and she assessed the resident's right ankle and observed faint bruising. RN B denied the resident complaining of any pain and stated the resident refused offers for an ice pack. In an interview on 06/13/14 at 2:56 PM CNA L stated she was the aide for Resident # 13 when she fell on [DATE]. CNA L stated after the fall Resident #13 just kept saying that her ankle hurt. CNA L stated she also worked the night following the fall and when she observed the resident's ankle it was bruised. CNA L stated she overheard RN B tell the resident's daughter she would ask the day shift to get x-rays of the resident's ankle. CNA L stated prior to the fall she had been assisting the resident with toileting, but she had not been aware that a UA was needed. CNA L described the resident's usual state as "alert". In an interview on 06/14/14 at 9:40 AM Physician A denied he was told about Resident #13 being so lethargic that she couldn ' t drink or swallow her medication. In an interview on 06/12/14 at 8:35 AM, the DON stated that her expectations for a UA are for staff to reattempt if the resident is noncompliant. In the first attempt, the DON stated that she expects that staff attempt twice within 24 hours and if not successful in obtaining the UA, to notify the Resident's physician. The DON stated that she expects staff to contact the doctor via phone, unless they are directed by the doctor to fax. The DON stated that the first step should always be to contact the doctor via phone. In regard to Resident #13, the DON stated that Physician A was in the facility prior to the resident's fall on Wednesday, 06/04/14. The DON stated that they informed Physician A during that visit that Resident #13 was resistant to providing a UA. Physician A informed staff to keep trying to obtain the UA. The DON stated that she does not know why it took four hours for staff to notify the doctor of Resident #13's fall on 06/05/14. The DON stated that Resident #13 was a one-person transfer prior to her fall but due to her non-weight bearing status, her method of transfer had been changed. The DON stated that Resident #13 did not have any routine or PRN pain medications prescribed to her prior to the fall. The DON stated that her expectation if a Resident falls and is experiencing pain, staff will contact the doctor's office and obtain an order for [REDACTED]. when the Resident experienced an increased change in condition. The DON stated a follow-up UA is not usually obtained when a resident has completed antibiotics for a UTI unless they are displaying signs and symptoms. The DON stated she was not aware of the labs received on 06/05/14 for Resident #13 that indicated abnormal levels. The DON stated that she is only notified of lab results if they are identified as being critical. In an interview on 06/12/14 at 9:15 AM LVN B stated that she was informed of Resident #13 ' s fall when she came to work at 6:00 AM on 06/06/14. LVN B stated prior to the fall on 06/05/14 night shift staff had reported to her that Resident #13 was experiencing increased confusion at night. LVN B stated Resident #13 had completed antibiotics for a UTI on 06/01/14 so on 06/03/14 she requested a follow-up UA and blood work to ensure the UTI had cleared up. LVN B denied anyone speaking to her about pain medication for Resident #13. LVN B stated Resident #13 was complaining of pain to her ankle during her shift and that the ankle was swollen, discolored, and tender to the touch. LVN B stated that Resident #13 indicated the ankle was causing her pain. LVN B stated that she informed the resident's physician about the condition of the ankle and the resident's pain, and an x-ray was ordered. LVN B stated that the doctor did not order pain medications and she did not request an order for [REDACTED].#13, but stated she did not attempt to obtain a UA due to focusing on Resident #13's ankle. LVN B stated that she next cared for Resident #13 on 06/07/14. LVN B stated on 06/07/14 Resident #13 had eaten lunch with the help of her husband, but then became lethargic. LVN B stated she faxed the resident's physician around 3:30 to inform him of the resident increase lethargy. LVN B described Resident #13 as responsive and having stable vital signs, and contributed her increase lethargy to her [MEDICATION NAME] and [MEDICATION NAME]. LVN B stated that in the fax she sent to the doctor she informed the doctor she was withholding the resident's [MEDICATION NAME] due to the increases sleepiness. LVN B stated her shift ended prior to receiving a response from Resident #13's physician. LVN B stated that the nurses do have the physician's cell phone number and are able to contact him directly if there is significant concern. LVN B stated that she cared for Resident #13 again on 06/08/14 during the day shift. LVN B stated she receive a report from the night nurse stating that the [MEDICATION NAME] had been withheld, but the resident was still "very groggy" and had slept through the night LVN B stated she assessed Resident #13 around 7:00 AM and found the resident had worsened and was running a fever. LVN B contacted the resident's physician and obtained an order to send Resident #13 to the hospital via EMS. LVN B denied any knowledge of the abnormal lab reports conducted on 06/05/14. LVN B stated that if she had been aware of the lab results she would have focused more on getting the UA and would not have been so focused on the [MEDICATION NAME] as the cause of the resident's lethargy. In an interview on 06/12/14 at 12:25 PM the DON stated that she observed Resident #13 after the fall but before the x-ray. The DON stated that she was not sure if it was the day of the fall or the next day. The DON stated she remembered observing the bruising on Resident #13's ankle. The DON could not remember which nurse was present when she assessed the resident. The Administrator stated that she never assessed Resident #13. The DON later provided the following written statement: On 06/05/14 in the morning I went to Resident #13's room with LVN A to assess resident's right ankle. Resident's right ankle had slight swelling and was starting to bruise. She was able to move it without any discomfort at that time. Instructed LVN A to call physician A to update him on resident. Physician A gave no new orders. On 06/06/14 in the morning I went to Resident 13's room with LVN B to assess resident's right ankle. Resident's right ankle had increased bruising and swelling, and resident had pain with movement. Physician A gave orders for an x-ray, and the results were given to him. He then ordered an ortho consult, which was set up for that afternoon. She went to her ortho appointment, her ankle was splinted, and she returned to the facility In an interview on 06/12/14 at 2:10 PM LVN A stated she worked on 06/05/14 from 6:00 AM to 6:00 PM. LVN A stated she was told about Resident #13's fall by the off going nurse, RN B. LVN A stated RN B described the injury as being bruised. LVN A stated RN B reported she did not know if the swelling to the right ankle was normal for the resident so had asked the resident's daughter to come look at the ankle. LVN A stated RN B described Resident #13 as having range of motion (ROM) in the identified ankle and was able to bear weight on it. LVN A stated when she assessed Resident #13 she found the resident to have a quarter size bruise on the top of her foot, normal [MEDICAL CONDITION], and appropriate ROM. LVN A denied Resident #13 complaining of pain. LVN A stated she notified Physician A of the resident's fall because that had not been done by RN B, and was told to "keep an eye" on the ankle. LVN A denied any x-rays being ordered. LVN A stated that she did not attempt to obtain a UA from Resident #13 because RN B had reported the resident was uncooperative. LVN A confirmed she had not reported to Physician A any concerns about obtaining the ordered UA. LVN A confirmed that she had received the abnormal lab results for Resident #13 on 06/05/14. LVN A stated she gave a verbal report to Physician A's nurse and then faxed the report to the Physician A's office. LVN A reported Physician A's nurse told her she would let the doctor know about the results. LVN A stated it is not normal procedure for the person receiving the lab results to notify anyone other than the doctor unless the results are identified as critical. LVN A stated lab results and the subsequent fax and phone call to the doctor are usually noted in the nurses noted. LVN A stated she "was not surprised" she had not documented the notification of the physician via phone or fax in the nurses' notes of Resident #13's clinical record. LVN A stated documentation in the nurses' notes just depends on if she has time to document and if she remembers to document. LVN A denied being concerned about the abnormal labs because the resident has a history of abnormal labs. LVN A reviewed Resident #13's abnormal lab report from 06/05/14 and identified high potassium as a possible indictor of a person's kidneys not funcitioning properly. LVN A stated she was not sure if potassium levels could be affected by a UTI. LVN A states she was not sure what GFR or chloride levels indicate or impact. Record review of Resident #13's clinical record revealed lab results for labs completed on 04/07/14, 04/11/14, and 05/15/14 by a local lab. On all of these dates the lab results identified Resident #13's potassium as "within range". In an interview on 06/12/14 at 3:44 PM LVN C stated that she was the charge nurse for Resident #13 on 06/06/14 from 6:00 PM to 6:00 AM. LVN C stated that she took over as charge nurse from LVN B on 06/06/14 and she could not remember if LVN B reported anything to her about Resident #13 being sleepy. LVN C stated that she did recall LVN B telling her she had spoken with the resident's physician and he said to hold the resident's [MEDICATION NAME] if sleepy. LVN C stated she went in to check on the resident around 7:00 PM and found that she could arouse the resident, but the resident wouldn't say awake. LVN C stated the resident would respond to a question and then fall asleep. LVN C stated that when she lifted the resident's blanket around the injured ankle the resident would stiffen as if anticipating pain. LVN C stated she administered a [MEDICATION NAME], but withheld all other medications because she did not feel the resident could stay wake enough to take the medications. LVN C stated the resident's lethargy did not concern her because the resident could answer questions. LVN C stated she checked on the resident again around 8:00 PM and the resident still responded to verbal stimuli. LVN C stated she contributed the resident's lethargy to the overall experience of the fall, fracture, doctor's appointment, and her [MEDICATION NAME] and [MEDICATION NAME]. LVN C stated that the resident was not normally this lethargic, but admitted she had only worked at the facility for approximately 3 weeks at the time of the incident and was not that familiar with the resident. LVN C states she never thought about contacting the doctor or getting another nurse's opinion on the resident. LVN C stated she was not aware of the doctor's order for a UA from 06/03/14, and that a lab request for a UA was on the 24 hour report for Monday. LVN C stated she never attempted to obtain a UA from the resident. LVN C stated she checked the resident's vitals twice during her shift, at approximately 9:30 PM and again at 3:30 AM, including oxygen saturation levels. LVN C could not explain why the assessment of the resident at 3:30 AM was not documented in the nurse's notes, but stated she remembers she was not concerned about the resident's condition. LVN C denied any knowledge of abnormal lab results received on 06/05/14 for the resident. LVN C stated that the increased glucose could indicate an infection, the increased chloride could indicate issues with the resident's kidney function, and high potassium could affect her heart. LVN C stated that if she had been aware of the labs she would have been more concerned with the resident's lethargy. LVN C stated critical labs are put on the 24 hour report, but abnormal lab results are just faxed to the doctor and put on the chart. LVN C stated she would not be aware of abnormal lab results unless she was specifically looking for them in the resident's chart. LVN C stated the nurses on each shift are responsible for check for lab results, and reporting the lab results to the doctor. LVN C stated that she has never been instructed at this facility to contact the ADON or DON regarding lab results. LVN C stated that if she had been aware of the resident's abnormal labs she would have contact the resident's physician and if she had been aware of the order for the UA she would have attempted to catheterize the resident. In an interview on 06/13/14 at 9:55 AM CNA E stated that she has been employed with the facility since September 2014. She stated that she worked the 2:00 PM to 10:00 PM shift on 06/07/14, and was the aide for Resident #13. CNA E described Resident #13 as "out of it", and stated the resident was so lethargic she did not want to give liquids to the resident for due to concern of aspiration. CNA E stated that the resident was "lethargic" the "whole night" and that to arouse the resident she had to physical shake her. CNA E stated the resident's skin was "clammy" and "moist all over". CNA E described Resident #13's usual behavior as "talkative", and stated the resident usually goes to the bathroom with assistance and eats well. CNA E stated that the resident is usually "on it" and knows to use her call light. CNA E confirmed she had reported her concerns regarding Resident #13 to the nurse (LVN C), who then went in to assess the resident. CNA E stated the week before the resident was sent to the hospital (on 06/08/14) the resident was experiencing increased confusion. CNA E denied any knowledge about the resident needing to provide a UA. CNA E stated the night before Resident #13 fell (06/04/14) the resident was "really out of it". Record reviw of Resident #13's Physician's Telephone Orders, dated 06/06/14, revealed the resident was prescribed [MEDICATION NAME] 5/325 PO Q 6 hours PRN. Record review of Resident #13's Individual Resident's Controlled Substance Record revealed [MEDICATION NAME] 5/325 was administered on 06/06/14 at 8:00 PM, 06/07/14 at 4:00 AM, and 06/07/14 at 1:00 PM. The record shows no [MEDICATION NAME] administered by LVN C on the evening of 06/07/14. Record review of Resident #13's June 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of Resident #13's Treatment Record revealed the resident's pain level was checked once every shift utilizing numeric rating scale 0 to 10. The record reflects that on 06/04/14 Resident #13's pain level was 0 on both shifts. On 06/05/14 Resident #13's pain level was documented as 0 on the day shift and 3 on the evening shift. On 06/06/14 the resident's pain level was documented as a 0 on the day shift and a 6 on the evening shift. On 06/07/14 the resident's pain level was documented as a 0 on both shifts. Record review of Resident #13's June 2014 Pain Flow Sheet revealed on 06/06/14 at 8:00 PM Resident #13 received [MEDICATION NAME] 5/325. The Pain Flow

IJ FINDINGS Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for three (Resident # 1, #13, and #17) of 17 residents reviewed for pain, assessments, wound care, and breathing treatments by failing to: a. Assess, evaluate, and provide pain relief interventions to ensure adequate relief for pain when Resident # 1 had a dressing change to the extensive skin tears to her left arm. b. Provide Resident #1 with the physician's preferred method of wound care due to lack of supplies. c. Assess, evaluate, and provide pain relief when Resident #13 fell (06/05/14) and complained of pain in her right ankle, subsequently revealed to be fractured. d. Assess, evaluate, and provide appropriate interventions when Resident #13 experienced a significant change in condition. On 06/07/14 Resident # 13 became lethargic and had limited responsiveness which resulted in staff withholding liquids due to fears of aspiration and withholding medications due to Resident #13 being unable to stay awake long enough to swallow the medication. On 06/08/14 Resident #13 was found to be unresponsive and was sent to the hospital via ambulance. e. Obtain a UA ordered by the physician on 06/03/04 for Resident #13, who was subsequently hosptalized on [DATE] with a [DIAGNOSES REDACTED]. On 06/13/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" at a "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. These failures placed the facility's 71 residents at risk for not being provided appropriate pain relief interventions, and not being assessed for a change in condition which could result in increased pain, serious medical complications, need for increased medication, decline in condition, the need for hospitalization , or death. NON IJ FINDINGS e. Assess Resident #1 prior to and after administering a breathing treatment f. Provider Resident #17 with wound care as ordered the physician These failure placed the facility's eight residents who receive breathing treatments and 12 residents who receive wound care at risk for increased medical complications [REDACTED]. The IJ findings include: Resident # 1 Record review of Resident #1 admission record revealed an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS dated [DATE] revealed she was limited to making concrete requests, could respond adequately to simple, direct communication only, was severely cognitively impaired, had no behaviors, was totally dependent on two persons for transfers, required extensive assistance of two persons for dressing, toileting, and bathing, required extensive of one person for eating and personal hygiene, was incontinent of bowel and bladder. An assessment of pain indicated she exhibited non-verbal sounds (moaned, groaned) and had facial expression (grimaces, wrinkled forehead, furrowed brow) daily. Record review of Resident #1 ' s Care Plan for Falls, Pain, High Risk for Increased Bleeding, and Activities of Daily Living, dated 3/18/14, revealed the following: Resident #1 was at risk for falls related to decreased mobility and poor upper body control and behaviors during care provided. Care Plan approach included to reproach resident at a later time if behaviors occurred and she was not easily redirected, call light was to remain within reach at all times, her personal items and frequently used items were to be kept within reach, observe frequently and place in supervised area when out of bed, and provide toileting assistance every two hours. A hand written note was noted at the bottom of care plan for falls, dated 6/7/14, indicating Resident #1 had an actual fall with Hoyer Lift. Resident #1 was at risk for pain/discomfort related to decreased mobility with history of generalized pain. Care Plan approach included to administer medication as ordered. (APAP, [MEDICATION NAME]). Monitor and record effectiveness ...Assess past effective and ineffective pain relief measures, evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, and aggravated factors. Monitor and record any non- verbal signs of pain: (e.g., crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal ...). Position for comfort with physical support as necessary. Use non-medicated pain relief measures: examples: bio-feedback, application of heat/cold, massage, physical therapy, stretching and strengthening exercises, acupuncture ...Monitor effectiveness. Resident #1 was a high risk for increased bleeding related to blood thinning agents ([MEDICATION NAME]). Care Plan approach included to hold pressure on areas of bleeding for 5 minutes or until stopped, lab as ordered, report abnormalities to physician, monitor for side effects, report to physician, notify physician if bleeding was not stopped with pressure, protect resident from bruising self. Resident #1 ' s Care Plan for Activities of Daily Living (ADL) Functional/Rehabilitation Potential revealed Resident #1 required assistance with ADL. Care Plan approach indicated Resident #1 needed assistance of two with transfers via hoyer lift due to double [MEDICAL CONDITION]. Resident #1 ' s Care Plan for Behavioral Symptoms, dated 6/9/14, indicated Resident #1 was demonstrating combative/anxious behavior during personal care and transfers, which put Resident #1 at risk for injuries... Care Plan approach included to utilize 3 staff members for use of hoyer lift with transfers ... In an interview on 6/9/14 at 5:00 p.m., the Administrator stated she had spoken with the DON about Resident #1 falling out of the mechanical lift on 6/07/14 around 10-11 a.m. The Administrator instructed the DON to call the Clinical Supervisor who told the DON because the injuries sustained from the fall were only skin tears it was not reportable to the state. The DON, Administrator, and Clinical Supervisor decided to make Resident #1 a 3rd person transfer via mechanical lift. Record review of Resident #1's "Nurse's Notes" dated 06/07/14 at 6:30 a.m. revealed, "Two CNA's (CNA G and CNA H) were transferring resident from bed to geri-chair using hoyer (mechanical) lift. Resident was properly placed in sling, but when resident became restless she shifted and the mechanical lift flipped over to the side. One of the CNA's stopped resident from hitting her head, and nurse was called to room at 5:45 a.m. Head to toe assessment performed. Resident has several skin tears from the bicep of her left arm down to the forearm of her left arm. Skin flaps were intact, they were cleaned and stretched back out and covered with a dressing. Resident also has some bruising to left leg. Resident was given medication for pain. Vital signs - 147/83, 98.1 degree temperature, 93 pulse, 22 respirations and 92% (oxygen saturation). Resident did not hit head according to CNAs. Dr... was informed ...and stated to keep resident under observation and daughter was called as well. Will continue to monitor. In an interview on 06/10/14 at 2:20 p.m. LVN C said that on 06/07/14 at about 5:45 a.m. she was at the nursing station when she heard a loud crash. LVN C said that she entered Resident #1's room and saw the mechanical lift flipped over, Resident #1 was on the floor still in the sling lying on her right side . . . . She said that she left the room to get supplies to clean her wounds. She said that she got normal saline, abdominal pads, Kerlix gauze, TAO, sterile water, Q-tips but could not find any steri-strips. She said that she looked in the supply closet and treatment cart but could not find the steri-strips. She said that she cleaned the wounds with normal saline, straightened out the skin tears with Q-tips, applied TAO, applied an abdominal pad over the wounds, and covered with Kerlix gauze. She said that she did not use steri-strips because could not find any. She described the wounds as extending from above the elbow down to her forearm. She said that she did not measure the wounds. Record review of LVN C's "Witness Statement" dated 06/10/14 revealed, "I, LVN C, approximately at 5:45 a.m. on 06/07/14 was standing at the medication cart when I heard a loud crash. I ran in the direction of the noise and when I reached room , I saw the resident had been dropped out of the hoyer (mechanical) lift . . . . When I touched the resident she immediately began to moan. . . . I then saw that she was bleeding from her left arm. . . . When I had assessed the resident I left her with the CNAs to get the supplies from the treatment cart. I did not find steri-strips in the cart or the medical supply closet so I got the long sticks to apply ointment in the sterile packaging, sterile gauze, sterile water, abd pad, and kerlix. I cleaned the area of her left arm with sterile water and sterile gauze and then proceeded to stretch the skin flaps back together. I then cleaned and patted the area dry applied TAO (triple antibiotic ointment), the abd pad, and asked the CNA (CNA G) to hold up the resident's arm to cover the area with kerlix. I then called Dr. and Dr. was on call and I described that the resident had been dropped out of the hoyer (mechanical) lift and had 3 skin tears to left arm, and bruising to left lower extremity area. I explained that she had diabetes type 2, was on [MEDICATION NAME], and was a double lower extremity [MEDICAL CONDITION]. He then asked me what I had done to the wound area and he stated that that was fine to continue to observe it over the weekend and call Dr. (Physician B/Resident #1's Dr.) on Monday morning so he could have a more detailed plan of wound care since he was more familiar with resident. I then called the daughter and told her that her mom had been dropped out of the hoyer (mechanical) lift and had skin tears on her left arm from her bicep to the bottom of her forearm. I then called DON, I left a message when I did not receive an answer. I then did my documentation and told the oncoming nurse what I had done and that the DON had not answered that I had left a message." In an observation on 06/09/14 at 3:10 p.m., Resident #1 was observed lying in her bed. CNA D and RN A were present conducting a dressing removal. Resident #1 was observed to have a large bandage on her left arm that covered from the middle of her forearm to above her elbow. The bandaged was covering most of the wound, but a small part of what appeared to be a larger wound was actively bleeding, and bright, fresh blood was noted on the bandage, the gauze being used by RN A to stop the bleeding, and on the resident's bed sheets. The bright red stain on the bed sheet covered an area from the resident's shoulder to below her elbow. RN A was observed pressing down on the wound with gauze to stop the bleeding. Resident #1's left arm was bandaged with gauze that was undated and covered in a substance that was dried, dark brown, and crusted. The substance appeared to be dried blood. Resident #1 was groaning, displaying facial grimacing, and watery eyes indicating she was in pain. These signs of pain increased when RN A attempted to remove the bandage from Resident #1's arm or pressed down on the injury with gauze. In an interview on 6/9/14 at about 3:10 p.m., RN A stated she had come into Resident #1's room because she was told by the charge nurse the wound to left arm was bleeding through the gauze and the dressing needed to be changed. RN A said she did not know how the injury to Resident #1's left arm had happened. RN A said she did not know when the dressing was applied because the dressing was not dated. RN A said she believed Resident #1 had received pain medication before lunch, as this was normally when she received medication, but that she was not sure of the time. RN A said the bandage to Resident #1 left arm was an abdominal pad, and that this was the wrong type of dressing for this type of wound. RN A stated that she did not confirm with the resident's nurse or by reviewing the resident's MAR indicated [REDACTED]. Record review of Resident #1's MAR indicated [REDACTED]. In an interview with LVN A on 06/09/14 at 3:20 p.m. she confirmed that Resident #1 had not received any pain medication that day. RN A continued to attempt to remove bandage while surveyor checked on status of pain medication. RN A was informed by surveyor that Resident #1 had not received any pain medication that day. The DON was informed on 06/09/14 at 3:25 PM by the surveyor about Resident #1's dressing change occuring without the resident receiving pain medication. The DON stated she was not aware of the dressing change occurring and stated she would intervene. On 06/09/14 at 3:30 PM LVN A confirmed she had just administered [MEDICATION NAME] to Resident #1 In an observation on 06/09/14 at 4:38 p.m., RN A was observed attempting to remove the dressing from Resident #1's left arm. Resident #1 was moaning, groaning, and displaying facial grimacing. The DON stopped RN A from removing dressing and told RN A Resident #1 would need more pain medication. The DON stated they would contact the resident's doctor and get an order for [REDACTED]. In an interview on 06/09/14 at 4:44 p.m. with the DON and RN A, they both said they did not know whether the dressing to Resident #1's left arm had been changed since Saturday (6/7/14). RN A said that the abdominal pad should have not been applied to skin tears with a flap because the abdominal pad adheres to the skin. In an interview on 06/09/14 at 5:03 p.m., LVN A said another dose of [MEDICATION NAME] for pain was administered at 5:00 p.m. In an observation on 06/09/14 at 5:26 p.m., RN A was observed attempting to remove Resident #1's dressing. RNA was observed to be applying vitamin A&D ointment in an attempt to help loosen the dressing from Resident #1's left arm. RN A said she could not remove the dressing from Resident #1's left arm because the dressing was stuck to Resident #1's skin tears. RN A said she did not know what to do and asked surveyor whether she wanted to remove the dressing. In an observation on 06/09/14 at 5:40 p.m., RN A was observed once again attempting to remove Resident #1's bandage. RN A was observed squirting with a syringe normal saline to the gauze and skin to left arm in an attempt to remove dressing from left arm. Resident #1 was crying and appeared to be in a lot of pain by displaying facial grimacing and groaning. RN A removed some of the dressing, for what surveyors could assess, Resident #1's skin tears were large. Skin tears had yellow beds with blood (it appeared to be adipose tissue). The edges of the wound were jagged. The DON looked at the wounds, she said the wounds were skin tears, and she did not know she was supposed to report skin tears. In an interview on 06/09/14 at 5:55 p.m., RN A stated her opinion was that the skin exposed to skin tears was adipose tissue, she said the skin tears were deep and not superficial. RN A stated she had called the doctor and reported the lacerations happened over the weekend and that the doctor had ordered steri-strips to be applied. In an observation on 06/09/14 at 6:02 p.m., revealed the dressing to Resident #1's left arm finally removed (two hours and 52 minutes since the surveyors became aware the dressing was in the procces of being removed). Three very large skin-tears observed with yellow beds (appearing to be adipose tissue) and blood; edges of wounds were jagged. Wounds were noted to be diagonal x 3 starting from upper arm to forearm. There were not any flaps noted to the wounds. In an interview on 06/09/14 at 3:50 p.m., the DON stated the incident involving Resident #1 had occurred on 6/7/14 and through interviews she discovered two CNAs were transferring Resident #1 when the mechanical lift tipped over. The DON stated Resident #1 did not go to the emergency room after the fall. She also stated she did think the facility had done an X-Ray to her wrist. The DON stated RN A was informed about Resident #1 on 06/09/14 morning. The DON stated she had not seen the wound and that she had found out about it on Saturday (06/07/14). She said she was called and LVN C had left her a message. The DON said that RN A should have checked Resident #1 for pain and if RN A was already in the process of changing the dressing and Resident appeared to be in pain, RN A should have stopped the dressing change and looked into giving her pain medication. The DON stated the skin tears were not measured because usually the facility did not measure skin tears. In an interview on 06/09/14 at 4:50 p.m. with the Administrator and the DON, the Administrator said the ADON was called in on Saturday because Resident #1 had fallen and had received a skin tear. The Administrator said the ADON had gone in and assessed the resident, but did not further assess the wound to left arm because Resident #1 already had bandages over the wound and the ADON was afraid to remove the dressing because Resident #1 was on [MEDICATION NAME]; the ADON was afraid the wound might start bleeding again. The DON said LVN C had left her a message about the incident on 06/07/14 around 6 a.m. The Administrator said the DON had called her, and she instructed the DON to call the Clinical Supervisor whom told the DON that skin tears were not reportable. The administrator stated what was concluded was that three people are needed to do transfers instead of two for Resident #1. In an interview with the Administrator and DON on 06/09/14 at 6:58 p.m., the DON and the Administrator both stated the wounds noted to Resident #1 left arm were skin tears and because of the medication [MEDICATION NAME] Resident #1 was on, the wounds looked a lot worse than what they were. The DON and the Administrator both stated they both felt they acted appropriately with what they knew. The DON said she was planning on looking at the skin-tears today. The DON stated the procedure was for the treatment nurse to treat wound, and then her staff would come get her so the DON could assess. The Administrator said she had a concern of what was reported to her because all she was told was that the injuries were skin tears. In regards to the information that was related to her, the Administrator said she would have to do education and training to for her nurses, so they (Administrator and DON) would know they are getting the whole picture. Both the DON and the Administrator stated that LVN C and the ADON needed to be educated and trained on how to address and report these things. The Administrator said that the dressings usually stay in place on skin tears for three days. So if the dressing to Resident #1 was applied on Saturday, then today would have been the day for the dressing to get changed. Record review of Resident #1's physician's orders [REDACTED]. Apply TAO and cover with non-adherent ([MEDICATION NAME]) dressings and reinforce with Kerlix (gauze dressing) wrap and secure with medifix tape every day T/H (til healed)." Record review of Resident #1's unsigned written physician's orders [REDACTED]. Observation on 06/12/14 at 9:10 a.m. revealed RN A provided wound care treatment for [REDACTED]. RN A spread A & D ointment on Resident #1's wounds after cleaning with wound care cleanser. "Vitamins A, D, and E topical (for the skin) is a skin protectant. It works by moisturizing and sealing the skin, and aids in skin healing. This medication is used to treat diaper rash, dry or chafed skin, and minor cuts or burns". <http://www.drugs.com/mtm/a-d-topical.html> In an interview on 6/12/14 at 11:50 a.m., RN A confirmed she had applied Vitamin A and D ointment to Resident #1's left arm. She said she had gotten a clarification to apply Vitamin A and D ointment instead of TAO (triple antibiotic ointment). RN A stated when she receives a telephone orders, she is responsible for transcribing the order. She said the reason why the TAR (Treatment Administration Record) did not have the correct transcription for Vitamin A and D ointment was because she had received the order late the night before and she just forgot to transcribe the order on the TAR. RN A stated the reason why the doctor was called for the clarification was because the facility had ran out of TAO. She said the doctor said that Vitamin A and D could be used since it had vitamins in it. RN A stated this was the first time the facility had ran out of TAO because RN A had been using it so much. TAO (triple antibiotic ointment) - [MEDICATION NAME], and [MEDICATION NAME] B are antibiotics that kill bacteria on your skin. [MEDICATION NAME], and [MEDICATION NAME] B topical (for the skin) is a combination medicine used as a first aid antibiotic to prevent infections in minor cuts, scrapes, [MEDICAL CONDITION] your skin. (http://www.drugs.com/mtm/triple-antibiotic-topical.html) In an interview on 06/10/14 at 6:45 p.m. Physician B said that the facility reported on 06/07/14 that Resident #1 had fallen from the mechanical lift and had skin tears. Physician B said that the skin tears were very extensive and he referred Resident #1 to an outside wound care clinic for treatment. Physician B said that his office had offered an appointment for Resident #1 yesterday (06/09/14) but the facility did not accept that appointment. Physician B said that his office did not have an opening on 06/10/14 but after receiving several phone calls from the facility, the office worked her in. In an interview on 06/13/14 at 1:00 p.m. Physician B said that he would have preferred that Resident #1 received the TAO, not A&D ointment during her wound care to her left arm wounds. Physician B said that the facility had called but he thought it was before he had examined Resident #1 and due to the extensive wounds, he would have preferred the TAO. In an interview on 06/17/14 at 11:22 a.m. the DON said that RN A did not report to her that the facility was out of TAO and she had used A&D ointment instead of the physician ordered TAO for Resident #1. She said that she thought that Resident #1 had received only one wound care treatment with A&D ointment and then TAO was started again. In an interview on 06/17/14 at 12:20 p.m. the Administrator said that after observing Resident #1's wounds on 06/09/14 she would have considered two of the wounds skin tears because they could be approximated. She said that the wound above Resident #1's elbow could be better described as a "laceration or abrasion" and not a skin tear. She said that Resident #1's wounds were not accurately described to her. She said that she was not aware that the facility was out TAO. The Administrator said that RN A should have reported to her that they were out of TAO and she would have purchased some more. She said that it was unacceptable to use A&D ointment she could have provided it and Resident #1 needed the antibacterial properties of the TAO. Record review of facility provided "Wound Care Policies and Procedures, Skin Tears Immediate Treatment, or Treatment Within 24 hours of Injury" dated 12/2011 revealed: "Flap Present ... 1) Cleanse area with normal saline. 2) Apply skin sealant to surrounding skin and allow it to dry. 3) Approximate skin flap (to intact surrounding skin) with gloved finger. 4) Stabilize approximated flap with steri-strips. 5) Leave steri-strips in place until healed. May cover with thin foam dressing if draining. 6) May cover with roll gauze to prevent patient/resident from disturbing. 7) Document wound care and wound appearance. Treatment Alternative 1) ...3) Apply wound [MEDICATION NAME] cream to wound and cover with a dry dressing (gauze) ... 5) Document wound care and wound appearance. PHYSICIAN ORDERS [REDACTED]. Resident #13 Record review of Resident #13's Admission Record Sheet, undated, revealed Resident #13 was a [AGE] year old female admitted to the facility initially on 08/02/213 and most recently on 02/18/14 and her [DIAGNOSES REDACTED]. Record review of Resident #13's most recent care plan, with multiple dates, revealed the following information: Problem: Resident has a history of falling; Goal: Resident will remain free from injury. Approaches include: Self Releasing lap belt. Tabs unit to bed and chair to alert staff resident attempting to rise alone. Scoop mattress to bed. Provide toileting assistance very 2 hours and PRN (dated 05/25/14) Problem: Resident Requires Assistance with ADLS's; Goal: Maintain a sense of dignity by being, clean, dry, odoar free and well groomed over the next 90 days; Approaches include: Assist of one in the area of bathing, bed mobility, dressing, and toileting. Assist of two with transfers (dated 11/27/13) Problem: Resident at risk for pain related to [MEDICAL CONDITION]; Goal: Resident will develop effective coping strategies to help adapt to pain; Approaches include: Administer medications as ordered and evaluate effectivenss. Assess effects of pain on the resident. Monitor and record any complaints of pain including location, frequency, effect on function, intensity, alleviating factors, aggravating factors. Monitor and record any non-verbal signs of pain. Use non- medicated pain relief measures and monitor effectivenss. (dated 11/27/13) Problem: Resident is demonstrating resisting of care and verbal aggressive behavior; Goal: Qualified staff will rule out physical/environmental causes and attempt non-pharmacological interventions to improve quality of life; Approaches include: Communicate resident status via 24 hour report. Initiate behavior monitoring flow record. Notify physician and family of any changes in resident status. (dated 11/27/13) Resident #13's clinical record also contained the following entries in the nurse's notes: 06/03/14 11:30 AM Vital signs 140/82 (blood pressure), 97.6 (temperature), 77 (pulse), 18 (respirations), Night nurse reports increased confusion in evening. Faxed Physician A to request for follow up UA (urine analysis) and C&S (blood test for protein levels). Signed by LVN B. 06/03/14 9:00 PM Resident has been non-compliant with care this evening. She refused her shower and refused to let CNA change her into pajamas. She became verbally and physically aggressive towards staff. She requested to get into bed but refused to under her blankets. Signed by LVN C. 06/03/14 Received fax with order to do UA with C&S and BMP (base metabolic panel), order written and lab faxed. Signed by LVN C 06/04/14 12:45 AM Lab here and resident refused to try to void in toilet in hat for UA. Signed by LVN C. 06/04/14 4:00 PM Physician A here to make rounds-medications changed. Resident's daughter made aware. Signed by LVN A. 06/05/14 4:15 AM CNA found resident lying in floor by bed. Unable to state what happen and if she hit her head. . .No injuries noted but stated right ankle hurt. Patient beared weight with transfer . . . Some [MEDICAL CONDITION] present to right ankle with no bruising. Unable to tell if [MEDICAL CONDITION] was present before fall. Up in wheelchair at desk . . . Elevated right foot and applied ice pack to ankle. Patient denied complaints of pain at present. Neurological checks begun. Notified daughter and asked she visit to determine possible injury to right ankle. Blood pressure 130/76, pulse 76, respirations 18, temperature 98. Signed by RN B. 06/05/14 9:45 AM Resident complained of generalized discomfort but has ROM (range of motion). . . Resident has generalized [MEDICAL CONDITION] to bilateral lower feet, ankles, and legs, bruising starting to form to right ankle. Physician A notified of fall, no new orders received. Signed by LVN A. 06/05/14 11:00 PM Have attempted several times to obtain UA. Patient refusing to have straight catheter performed. When placed on bed side commode refuses to void then wets diaper. Daughter visited to assist staff. Patient refused her also. Patient complains of pain to right ankle. No [MEDICAL CONDITION] noted. Refusing to stand on right foot. Daughter requested x-ray be done tomorrow. Stated we would notify MD in AM. Ice pack applied for comfort. Patient has episodes of confusion. Signed by RN B. Record review of Resident #13's clinical record revealed a lab report, dated 06/05/14, detailing results of a BMP (Basic Metabolic Panel). The report identified three lab values that were elevated: Potassium 5.3 (reference range 3.5-5.1), Chloride 110 (reference range 98-107), and Glucose 141 (reference range 65-105). The report also identified one area that was low: GFR 54 (reference range >60) The National Kidney Foundation identifies potassium as an "important mineral found throughout our bodies. Potassium . . . plays a very important role in keeping your heartbeat regular and your muscles working properly. . . . Potassium levels that are too high or too low can cause health problems. . . . Without the ability to remove excess potassium, levels can rise and lead to serious health problems." http://www.kidney.org/news/monthly/potassiumCKD.cfm?homestatic=PhosphorusInfographic The National Library of Medicine identified chloride as "a type of electrolyte. . . . These substances help keep the proper balance of body fluids and maintain the body's acid-base balance." http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm The National Library of Medicine identified Glomerular filtration rate (GFR) as "a test used to check how well the kidneys are working. . . . Levels below 60 mL/min/1.73 m2 for 3 or more months are a sign of [MEDICAL CONDITION]. GFR result lower than 15 mL/min/1.73 m2 is a sign of kidney failure and requires immediate medical attention." http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Record review of Resident #13's clinical record also revealed the following entries in the nurse's notes: 06/06/14 5:30 AM Patient continues to refuse to use bed side commode or allow nurse to catheterize her for UA specimen. Will alert oncoming shift. Signed by RN B. 06/06/14 6:45 AM Resident right ankle is bruised and swollen. Resident could not bear weight on right foot. Notified Physician A and new order received to x-ray right ankle. Notified mobile x-ray and resident daughter. Signed by LVN B. 06/06/14 9:00 AM Mobile x-ray at facility. Signed by LVN B. 06/06/14 9:30 AM x-ray report received (indicating fracture of right ankle). Called Physician A cell phone and left voice mail, notified his office nurse via voice mail and faxed x-ray report to his office. Notified DON and residents daughter of x-ray results. Signed by LVN B Record review of Resident #13's clinical record revealed a final x-ray report from mobile imaging, dated 06/06/14, for Resident #13's right ankle that provided the following impression: mildly displaced bimalleolar [MEDICAL CONDITION] ankle. The American Academy of Orthopedic Surgeons identify an ankle fracture as when one or more of the bones that make up the ankle joint "are broken" . The Academy identify the bones of the ankle as the tibia (shinbone), fibula (smaller bone of the lower leg), and the talus (a small bone that sits between the heel bone and the tibia and fibula " . The Academy identifies a bimalleolar fracture as when the " tibia and fibula are broken ". http://orthoinfo.aaos.org

Based on interview and record review the facility failed to implement their policy to prevent abuse/neglect for three of seventeen residents (Resident #3, #15, and #16) reviewed for incidents of abuse/neglect. The facility failed to recognize, assess, and intervene timely as evidenced by: a. The facility failed to investigate, protect, and report allegations of abuse, LVN A physically and verbally abused Resident #3, #15, and #16. b. CNA A, B, and C failed to report and protect Residents #3 and #16 from being abused by LVN A. On 06/13/14 IJ was identified. While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of potential for more than minimal harm and scope of "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. This failure could affect all 71 residents residing in the facility by placing them at risk for abuse or neglect. The findings included: Resident #3 Record review of Resident #3's Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 3/17/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) could not be conducted because Resident #1 was rarely/never understood. Under C1000 Cognitive Skills for Daily Decision Making revealed that Resident #3 had scored a "3", indicating her cognition was severely impaired with making decision regarding task of daily life. Section G: Activities of Daily Living (ADL) Assistance, G0110 indicated Resident #3 was totally dependent with the assistance of one staff with eating/drinking. In an observation on 6/13/14 at 1:20 p.m., revealed Resident #3 lying in bed with head of bed elevated at 15 degrees. Resident #3 was asked her name or how she was doing by surveyor, Resident #3 would just look at her television and would not acknowledged surveyor was present in the room. No obvious injuries or suspicious bruising was noted on body. Resident #3 appeared well groomed. Resident #15 Record review of Resident #15's Admission Record Sheet, undated, revealed a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 5/02/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) score as "0", indicating Resident #15's cognition was not intact. Section E: Behavior reflected Resident #15 did not exhibit physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others. Section G: Functional Status indicated Resident #15 required extensive assistance of one person with bed mobility, and extensive assistance of two or more person physical assistance for transfers. Resident #16 Record review of Resident #16's Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #16's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 4/17/14, reflected Resident #16's Brief Interview for Mental Status (BIMS) score as "99", indicating Resident #16 was unable to complete interview. Under C1000 Cognitive Skills for Daily Decision Making revealed that Resident #16 had scored a "3" , indicating her cognition was severely impaired with making decision regarding task of daily life. Section G Functional Status indicated Resident #16 required extensive assistance of two or more person physical assistance for bed mobility and transfers. In an observation on 6/19/14 at 9:43 a.m., revealed Resident #16 was sitting up in her wheelchair in the dining room in the locked unit. Resident #16 did not know her name or where she was at. All Resident #16 would say was that "it's kind of cold". A CNA brought Resident #16 a blanket and covered her legs. No obvious bruising or suspicious injuries were noted on Resident #16. Interviews: In an interview on 6/11/14 at 12:08 p.m., CNA A stated that if she saw a resident being abused by another staff member, she was trained to report it immediately and protect the resident by removing resident from that area. CNA also stated she had been trained to report suspected abuse so it could be investigated. In an interview on 6/11/14 at 12:15 p.m., CNA A stated that even if staff followed the chain of command nothing gets done. CNA A stated that CNA B had told CNA A that LVN A was reported by CNA B because LVN A was very verbally abusive towards residents. CNA A said alleged verbal abuse was reported to the DON, but nothing was done about it. CNA A stated one time Resident #3 was in the dining room, LVN A was giving Resident #3 a protein shake, when Resident #3 would not drink the shake, LVN A grabbed Resident #3's face and opened her mouth and told Resident #3 to drink her shake because she did not have time for that. CNA A did not report it to the Administrator because CNA B had just reported LVN A for being rude and nothing was done about it. CNA A did not indicate that she removed Resident #3 from harm during witnessed abuse. Record review of CNA A's witness statement obtained by the surveyors, dated 6/13/14, indicated that CNA A had witnessed many times LVN A be verbally and physically abusive towards Resident #3. Her statement indicated that during breakfast times, when LVN A was passing out her morning meds, she would approach Resident #3 and say, " Okay, it's time for you to take your drink and I don't want any bullshit from you because I'm not in the mood." CNA A also wrote that while LVN A would be forcing Resident #3 to drink, the drink would run down the side of Resident #3's mouth. CNA A wrote there had been times that Resident #3 would start coughing because of the liquid being forced and LVN A not giving Resident #3 time to swallow. In an interview on 6/11/14 at 1:00 p.m., CNA B stated in February or March 2014 Resident #15 was in the hallway, acting out, "throwing a fit." CNA B stated LVN A got in front of Resident #15 and pressed down on his shoulder by pinching Resident #15's shoulder down, and then LVN A told Resident #15 "she was not going to put up with it today." CNA B stated all of this had occurred before the administrator had arrived to work. When the Administrator arrived to the facility the incident was reported by CNA B to the Administrator. CNA B said after the administrator had spoken to LVN A, LVN A approached CNA B and asked her whether she had "turned her in for anything". CNA B said she did not know whether anything had been done about it. CNA B said she had witnessed LVN A being rude to other residents, but she could not remember what was said exactly. In a second interview on 6/11/14 at 2:51 p.m., CNA B stated she reported the incident with Resident #15 and LVN A to the Administrator the morning that it occurred. CNA B stated she was not asked to write a statement. CNA B stated she remembered another incident involving LVN A. CNA B stated when Resident #16 lived on the east side (where LVN A usually worked), Resident #16 had a tendency to try to get out of bed after being put in bed. CNA B said she would report it to LVN A, who then would go into Resident #16's room and push her back down against the bed and tell Resident #16 she did not have time for that. CNA B stated she verbally report it this incident to the former Administrator. CNA B did not indicate that she removed Resident #16 from harm during witnessed abuse. In an interview on 6/11/14 at 1:20 p.m., CNA C stated every morning during breakfast times LVN A grabs Resident #3's face by grabbing her cheeks, and pushes her forehead back, and shoves with a wooden spoon, the crushed medicine mixed with pudding, into Resident #3's mouth. CNA C stated she had also witnessed LVN A give Resident #3 her milkshakes in the same manner. CNA C stated when Resident #16 was living on the east side (where LVN A usually worked), Resident #16 would try to get out of bed, LVN A would push Resident #16's forehead and tell her to lie down. CNA C said this incident was reported to the former ADON, who no longer worked at the facility. CNA C stated they had quit reporting LVN A because nothing was done about it. CNA C did not indicate that she removed Resident #3 and #16 from harm during the witnessed abuse. In an interview on 6/16/14 at 1:00 p.m., CNA M stated former ADON had quit working for the facility one week before he was terminated. CNA M stated he was terminated by the facility on 6/09/14. Record review of CNA C's witness statement obtained by the surveyors, dated 6/13/14, indicated that CNA C had witnessed LVN A forcing medicine into Resident #3's mouth while grabbing her by her cheeks ...CNA C also wrote when Resident #16 would try to get out of bed, LVN A would shove Resident #16 down with her hands and say, "I don't have time for this[***]!! Go to sleep" ...CNA C wrote that she reported these things to the former ADON, and the current DON, whom would always say, "okay we will take care of it," and nothing would get done. In an interview on 6/11/14 at 3:56 p.m., the Administrator stated when verbal reports of abuse are made by staff, the allegations are handled immediately. She said the facility takes statements from the reporters and give the alleged perpetrator an opportunity to write a statement. The Administrator said, she then suspends the alleged perpetrator until the investigation was finished. In an interview on 6/12/14 at 2:50 p.m., LVN A stated she had never been talked to or been reported for being abusive towards residents. LVN A said whenever she is giving medication, she takes her time with her residents. She said that she gives Resident #3 her Glucerna in the morning and that Resident #3 requires her assistance. LVN A states she assist Resident #3 with drinking her Glucerna by placing her hand over Resident #3's hand while Resident #3 holds her own cup. She said she might sometimes put her hand behind Resident #3's head and tilt her head a little bit, but that she is always gentle. LVN A said she had never pushed or made any resident stay in bed, or mishandle or been verbally abusive against any residents. LVN A said when CNAs report to her that residents are acting out in the hallway or if the residents try to get out of bed; she goes and assesses the residents to see what is wrong and tries to investigate the underlining reason behind the behavior. LVN A denied ever grabbing Resident #3's face, making her drink the shakes, or telling Resident #3 she did not have time for her. LVN A denied ever pinching/pushing Resident #15 down while in the hallway while Resident #15 was in his wheelchair due to behaviors. LVN A denies ever pushing Resident #16 against her bed or pushing her forehead because Resident #16 was trying to get out of bed. LVN A said she always took time with her residents. In an interview on 6/13/14 at 9:55 a.m., the Administrator stated she was the Abuse Coordinator. The Administrator stated LVN A had not been reported for grabbing Resident #3's face while LVN A was giving her shakes or administering medications in the mornings. The Administrator stated LVN A had not been reported for pushing Resident #16 down in the bed when she was trying to get out of bed. The Administrator stated a CNA reported LVN A for pushing too hard on Resident #15's shoulder while Resident #15 was in the hallway. The Administrator said she investigated the incident and took statements, and after the investigation was completed, it was determined by the facility that LVN A was "just resting" her hand on Resident #15's shoulder. The Administrator also stated she had not reported the incident to the state. She said normally when allegations are made against someone; she puts that investigation in the staff's personnel file. The Administrator said she would have to look through her stuff to see where that investigation was at. In an interview on 6/13/14 at 10:10 a.m., the Administrator handed LVN A's personnel file to surveyor and stated there was not any documentation in LVN A's personnel file concerning Resident #15's incident, but that there should be some documentation about it in LVN A's file. The Administrator said she did not know why her staff was not reporting abuse to her. In an interview on 6/13/14 at 10:50 a.m., the Administrator said she did not do a written investigation, but completed a verbal investigation regarding CNA A's report of LVN A pushing and pinching downward on Resident #15's shoulder. The Administrator then said, "My bad." In an interview on 6/17/14 at 12:00 p.m., the DON stated no staff had ever reported LVN A for abuse to her. Record review on 6/12/14 of LVN A personnel files did not revealed any documentation related to LVN A being investigated or counseled over any type of abuse. Record review of Grievance Logs from September 2013-June 2013 revealed no documentation concerning Resident #15 and LVN A. Record review of the Facility's Leadership Policies and Procedures: Abuse, Neglect and Misappropriation, revised on 05/01/13, revealed "The facility's Leadership prohibits neglect, mental or physical abuse ... The facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and/or funds. The facility's Leadership will provide notification to the proper authorities . . . The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident . . ." According to the facility's abuse policy "staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types of abuse include but are not limited to physical assault/abuse . . . mental abuse . . . verbal abuse . . . neglect . . . All alleged violations concerns abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator . . . and other enforcement agencies according to state law including the State Survey and Certification Agency . . . The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken . . . The investigation may include but is not limited to the following: Identification and removal of the alleged perpetrators . . .Written summaries of interviews with individuals having firsthand knowledge of the incident . . . Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer . . .In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process . . . Guidelines for Investigation: Immediately assess the resident/patient at the time of discovery of alleged abuse. Document assessment in the medical record. Maintain the resident's/patient's protection during the investigation . . . Protection: During the investigation, the facility protect the patient/resident, as appropriate, including but not limited to the following: Removal of the alleged abuser from the patient/resident care setting. Enforcing a zero tolerance standard for retaliation against the alleged victim." This was determined to be Immediate Jeopardy (IJ) on 06/13/14 at 2:00 PM and the Administrator, DON, RN Consultant, and RN Regulatory Compliance Consultant were notified. The following Plan of Abatement was submitted by the facility on 06/19/14 at 9:30 AM: Failure to report and investigate: 1. The identified allegation SR14- 2 was reported on 06/13/14, reported to the Texas Department of Aging and Disability on 06/13/14. Regional Vice President will oversee any investigative process in the absence of the Administrator for a completed and thorough investigation until conclusion effective 06/13/14. The alleged perpetrator was suspended pending investigation on 06/13/14. The investigation of this allegation of abuse did include interview of staff who have worked with the alleged perpetrator around the time the resident reports the incident occurred. The Social Worker, has interviewed alert and oriented residents who reside on any unit the alleged perpetrator has worked 06/14/14. 2. Any allegation of abuse, neglect, exploitation or improper physical restraint of a resident will be called to the Texas Department of Aging and Disability. All allegations of abuse, neglect, exploitation of a resident have been reported to the Texas Department of Aging and Disability within 24 hours of identification, thoroughly investigated, documented, and the results of that investigation reported in five working days to the Texas Department of Aging and Disability by the Administrator and/or Regional Vice President. The Social Worker has completed an interview with all interviewable current in-house residents regarding any concerns the resident may have on abuse, neglect, exploitation of property 06/14/14. The Regional Vice President and Clinical Service Director have completed interviews with current employees regarding any concerns they may have focusing on abuse, neglect or exploitation of property 06/16/14. If during the initial interview process the Administrator becomes aware of any resident concerns or employee concerns regarding abuse, neglect or exploitation of goods, the issue will be documented and reported to the Texas Department of Aging and Disability within 24 hours, and immediate investigation will ensue. This investigation will be submitted to the Texas Department of Aging and Disability in five working days of reporting. If during the initial interview process the Administrator becomes aware of resident concerns that are not state reportable, a grievance form will be completed, and an investigation into the resident's concerns will ensue. Outcomes of the investigation into the grievance and the resolution will be discussed with the resident. 3. The Administrator and Director of Nursing have been reeducated by the Clinical Service Director that all allegations of abuse, neglect, exploitation of a resident have been reported to the Texas Department of Aging and Disability within 24 hours of identification, thoroughly investigated, documented, and the results of that investigation reported in five working days to the Texas Department of Aging and Disability by the Administrator and/or regional vice resident 06/10/14. The Administrator has been suspended pending investigation 06/13/14. The Administrator was brought back 06/16/14 with reeducation on confidentiality, sensitivity training, and final written counseling. The Clinical Services Director and a fundamental clinical operational services regulatory team member have reeducated all staff including housekeeping and therapy staff on immediate reporting of any suspected abuse and neglect of a resident to the abuse coordinator initiated on 06/13/14, and will continue until 100% compliance achieved. Facility staff has been reeducated that the facility In-Touch Line is a communication tool which provides all staff/patients/residents/family/friends etc., with an outlet to express any complaints or concerns they may have to an impartial source. Reports can be made by calling the In-Touch Line at [PHONE NUMBER] or the Texas Department of Aging and Disability. A representative of the Fundamental Clinical Operational Clinical Services Department will be present onsite daily until all aspects of this abatement plan have been fully implemented and sustained compliance as evidenced by ongoing audits of incident reports, grievances, and resident interviews. In progress. The Regional Vice President in the absence of the Administrator will review all allegations of abuse and grievances for appropriate follow up per facility policy and procedure. 4. The Quality Assurance Performance Improvement Committee will review allegations of abuse and grievances monthly times three months and then quarterly until the quality assurance performance improvement committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. Observations made by surveyors between 06/13-06/19/14 revealed no concerns regarding abuse or neglect. Interviews with facility staff between 06/13/14-06/19/14 revealed staff was able to identify the following: Different types of abuse The facility ' s Abuse Coordinator, Appropriate methods for ensuring resident safety and reporting abuse In an interview on 06/19/18 at 9:45 a.m. the Social Worker said that she has done resident interviews with those residents who are interviewable regarding abuse. The Social Worker said that any concerns revealed were reported to the Administrator. She said that she had not conducted satisfaction interviews with residents prior to the identification of the IJ. She said that this was part of the plan to help identify and prevent future abuse. Record review of Facility's In-Service Training Report, dated 6/13/14, revealed RN VPRC had in-serviced facility staff on Abuse/Neglect to address the IJ in the area of failure to report and investigate. The in-service instructed staff that "All incidents must be reported, if you witnessed something you need to report to your immediate supervisor, if unable to tell immediate supervisor then go through the chain of command ... All identified issues is to be reported immediately within a 24 hour timeframe ...All identified issues must be thoroughly investigated with documentation to support findings ...Always remember an allegation is reported first and then thoroughly investigated and followed up with a 5 day follow up report. The abuse coordinator is the Administrator..." Sign in sheets were provided to show staff's attendance at the in-service. Interviews with two CNAs on 06/15/14 revealed they had been re-inserviced on Abuse and Neglect. While the IJ was removed on 06/19/14, the facility remained out of compliance at a level of potential for more than minimal harm and scope of "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. Record review of the facility's Form CMS-802, undated, provided by the facility upon entrance 6/09/14, indicated 71 residents resided in this facility.

IJ FINDINGS Based on observations, interviews and record reviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 3 of 12 residents (Residents #1, #3, and #13) reviewed for the use of mechanical lifts. A. Facility staff failed to correctly operate the mechanical lift according to the manufacturer ' s user manual while conducting a transfer of Resident #1. The legs of the mechanical lift were not opened fully which contributed to the lift falling over while Resident #1 was in the sling, resulting in significant skin tears to the resident's left arm. B. The facility failed to provide training and monitoring regarding the use of the mechanical lifts to direct care staff. C. Facility staff failed to correctly operate the mechanical lift according to the manufacturer ' s user manual while conducting a transfer of Resident #3. D. Facility staff failed to utilize a mechanical lift when transferring Resident #13, who was previously identified as a requiring a mechanical lift due to non-weight bearing status, resulting in a fracture to her left leg. An Immediate Jeopardy (IJ) was identified on 06/10/14. While the IJ was removed on 06/19/14, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern" due to the facility was monitoring the implementation of the Plan of Removal. These failures could place 17 residents who utilize the mechanical lifts at risk of injury. IJ Findings included: Record review of Resident #1 admission record, undated, revealed an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS dated [DATE] revealed she was limited to making concrete requests, could respond adequately to simple, direct communication only, was severely cognitively impaired, had no behaviors, was totally dependent on two persons for transfers, required extensive assistance of two persons for dressing, toileting, and bathing, required extensive of one person for eating and personal hygiene, was incontinent of bowel and bladder. A staff assessment of pain indicated she exhibited non-verbal sounds (moaned, groaned) and had facial expression (grimaces, wrinkled forehead, furrowed brow) daily. Record review of Resident #1 ' s care plan, dated 5/26/17, revealed the resident had been identified on 03/18/14 as having problems in the area of ADL Functional/Rehabilitation Potential. The care plan stated the resident required assistance with ADL. The goal was for Resident #1 to " maintain a sense of dignity by being clean, dry, odor free and well groomed over the next 90 days " . The approach to transfers was " two person assist " via " Hoyer lift " . Record review of Resident #1's "Nurse's Notes" dated 06/07/14 at 6:30 a.m. revealed, "Two CNA's (CNA G and CNA H) were transferring resident from bed to geri-chair using hoyer (mechanical) lift. Resident was properly placed in sling, but when resident became restless she shifted and the mechanical lift flipped over to the side. One of the CNA's stopped resident from hitting her head, and nurse was called to room at 5:45 a.m. Head to toe assessment performed. Resident has several skin tears from the bicep of her left arm down to the forearm of her left arm. Skin flaps were intact, they were cleaned and stretched back out and covered with a dressing. Resident also has some bruising to left leg. Resident was given medication for pain. Vital signs - 147/83, 98.1 degree temperature, 93 pulse, 22 respirations and 92% (oxygen saturation). Resident did not hit head according to CNAs. Dr... was informed ...and stated to keep resident under observation and daughter was called as well. Will continue to monitor. In an interview on 06/10/14 at 4:30 p.m. CNA H said that on 06/07/14 she and CNA G were attempting to transfer Resident #1 from her bed to her geri-chair when Resident #1 and the lift fell over. CNA H said that she was steering the mechanical lift and CNA G was on the other side with Resident #1. CNA H said that she did not know if the mechanical lift legs were in the open or closed position when the lift fell over with Resident #1 because the geri-chair was obstructing her view. She said that Resident #1 was in the sling and was hovering over the geri-chair when the lift and Resident #1 fell over to the left. She said that another CNA had warned her that the legs on the lift sometime closed on their own without warning. She said that she had not reported this to anyone. In an interview and observation on 06/10/14 at 4:50 p.m. CNA G said that on 06/07/14 she and CNA H were attempting to transfer Resident #1 from her bed to her geri-chair. CNA G said that CNA H pushed the mechanical lift under Resident #1's bed and then each of them placed the loops of the slings onto the lift hooks. She said that CNA H was steering the lift and then she demonstrated two consecutive times how the transfer occurred. She said that CNA H put the legs of the mechanical lift underneath Resident #1's bed with the legs together, the sling was attached to the lift, CNA H backed the lift away from the bed, opened the legs wide, moved the lift to the geri-chair, and then closed the legs of the lift to place underneath the geri-chair. CNA G said at that time Resident #1 shifted in the sling and the lift and Resident #1 fell to the left and Resident #1 landed on the floor on her right side with the sling still in place and her head on CNA G ' s lap. CNA G said that it happened so fast and that she tried to catch Resident #1's head so that it would not hit the floor. In an interview on 06/10/14 at 2:20 p.m. LVN C said that on 06/07/14 at about 5:45 a.m. she was at the nursing station when she heard a loud crash. LVN C said that she entered Resident #1's room and saw the mechanical lift flipped over, Resident #1 was on the floor still in the sling lying on her right side. She said that Resident #1 had her head on CNA G's lap She said that she unhooked the sling from the mechanical lift and laid Resident #1 on her back to assess her. She said that she saw bleeding and discoloration on her left arm. She described the wounds as extending from above the elbow down to her forearm. She said that she did not measure the wounds. Record review of LVN C's "Witness Statement" dated 06/10/14 revealed, "I, LVN C, approximately at 5:45 a.m. on 06/07/14 was standing at the medication cart when I heard a loud crash. I ran in the direction of the noise and when I reached room , I saw the resident had been dropped out of the hoyer (mechanical) lift, and CNA H was yelling for the nurse. The other CNA had her right leg underneath the residents head ...When I touched the resident she immediately began to moan ...I then called Dr. and Dr. was on call and I described that the resident had been dropped out of the hoyer (mechanical) lift and had 3 skin tears to left arm, and bruising to left lower extremity area. I explained that she had diabetes type 2, was on coumadin, and was a double lower extremity amputee ...I then called the daughter and told her that her mom had been dropped out of the hoyer (mechanical) lift and had skin tears on her left arm from her bicep to the bottom of her forearm. I then called DON, I left a message when I did not receive an answer. I then did my documentation and told the oncoming nurse what I had done and that the DON had not answered that I had left a message." In an interview on 06/09/14 at 3:50 p.m., the DON stated the incident involving Resident #1 had occurred on 6/7/14 and through interviews she discovered two CNAs were transferring Resident #1 when the mechanical lift tipped over. The DON stated Resident #1 did not go to the emergency room after the fall. In an interview on 06/09/14 at 4:50 p.m. with the Administrator and the DON, the Administrator said the ADON was called in on Saturday because Resident #1 had fallen and had received a skin tear. The Administrator said the ADON had gone in and assessed the resident, but did not further assess the wound to left arm because Resident #1 already had bandages over the wound and the ADON was afraid to remove the dressing because Resident #1 was on Coumadin; the ADON was afraid the wound might start bleeding again. The DON said LVN C had left her a message about the incident on 06/07/14 around 6 a.m. The Administrator said the DON had called her, and she instructed the DON to call the Clinical Supervisor whom told the DON that skin tears were not reportable. The administrator stated what was concluded was that three people are needed to do transfers instead of two for Resident #1. Record review of the "Invacare Reliant 600 Manual/Electric Portable Patient Lift User Manual" dated 2011 provided by the facility as the user manual for the two mechanical lifts the facility provided for resident transfers revealed the following: Page 7 - Safety WARNING " ...Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient... Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted." Page 9 - Lifting the Patient " When using an adjustable base lift, the legs MUST be in the maximum Open/Locked position before lifting the patient. " Page 20 - Closing/Opening the Legs of the Base Assembly " The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to lose the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. " Page 21- Closing the Legs " 1. Stand at the rear of the patient lift and grasp the shifter handle with one hand and place the opposite hand on the steering handle of the mast for balance. The shifter handle MUST lock into its mounting slot to lock the legs in the full closed position. WARNING If the shifter handle is NOT positioned completely into its mounting slot, DO NOT use the patient lift until the shifter handle is properly seated and the legs of the patient lift are locked in place. Otherwise, injury and/or damage may occur. 2. Pull the shifter handle away from the patient lift and then to your left until it locks in the notch of the bracket. Page 21 - Opening the Legs " 1. Stand at the rear of the patient lift and grasp the shifter handle with one hand and place the opposite hand on the steering handle of the mast for balance. The shifter handle MUST lock into its mounting slot to lock the legs in the full closed position. " 2. Pull the shifter handle away from the patient lift and then to your right." Page 22 - Raising/Lowering a Manual/Hydraulic Lift WARNING " Invacare does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object." Page 29 - Attaching Slings to the Lift " 1. Attach the straps of the sling over hooks of the swivel bar. 2. Match the corresponding colors on each side of the sling for an even lift of the patient." In an interview on 06/10/14 at 5:20 p.m. the ADON said that she had investigated Resident #1's fall from the mechanical lift. The ADON said that she worked the day 06/07/14 that Resident #1 fell over with the mechanical lift. She said that she had done some mechanical lift in-services after the accident. She said that no proficiency skills have been done prior to the accident nor have they been done during orientation. She said that she had spoken to CNA H by phone and was told that the mechanical lift legs were together under the bed of Resident #1 and the legs were opened when she was moved away from bed toward the geri-chair. In an interview on 06/10/14 at 7:55 p.m. the DON said that the ADON had started the investigation regarding Resident #1's fall from the mechanical lift. She said that LVN C, CNA G, and CNA H had been interviewed. She said that the conclusion of the investigation currently was that Resident #1was too heavy and was moving around. She said that she had stopped her investigation because of the survey team. She said that she had not provided training or monitoring of staff regarding the use of the mechanical lifts. She said that she did not know if the ADON had provided training or monitoring of staff regarding the use of the mechanical lifts. She said that she had been the DON since 06/2013. She said she was responsible for monitoring and ensuring that staff was trained. She provided a form, "Staff Education/Orientation Policies and Procedures, Nursing Competency - Use of Mechanical Lifts" form dated 07/01/2013 and said had planned to use this form but had not yet. However, the DON said that the form did not exactly match the instructions related to their mechanical lift. Observation on 06/10/14 at 6:20 p.m. revealed CNA I and CNA J transferred Resident #11 from her wheelchair to her bed. CNA J pushed the mechanical lift toward Resident #11's wheelchair, opened the legs of the lift underneath the wheelchair, locked the two back wheels and attached the loops to the sling. The black loops of the sling were hooked onto the lift at Resident #11's legs and the green loops of the sling were hooked onto the lift at Resident #11's head. CNA J said that there were colored loops to attach the sling to the lift (red, green, blue, and black) but that it was difficult to distinguish between the colors because they had faded. CNA J using the remote control lifted Resident #11 from her wheelchair, unlocked the back two wheels, moved the lift (with legs wide open) underneath the bed. CNA J locked the two back wheel locks, lowered Resident #11 onto the bed, unhooked the loops from the lift, unlocked the two back wheel locks, and moved the lift out from under the bed. Page 22 - Raising/Lowering a Manual/Hydraulic Lift WARNING " Invacare does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object." In an interview on 06/10/14 at 6:35 p.m. CNA J said that she locked the back wheels of the lift when the resident was over the wheelchair and when over the bed. CNA J said that she had not been trained at this facility regarding transferring residents with the mechanical lift but had been trained at other places she had worked. CNA J said that she had been trained to lock the back wheels of the mechanical lift at different times during a transfer. In an observation on 06/09/14 at 6:02 p.m., revealed the dressing to Resident #1's left arm had been removed. Three very large skin-tears observed with yellow beds (appearing to be adipose tissue) and blood; edges of wounds were jagged. Wounds were noted to be diagonal x 3 starting from upper arm to forearm. There were not any flaps noted to the wounds. In an interview on 06/10/14 at 6:45 p.m. Physician B said that the facility reported on 06/07/14 that Resident #1 had fallen from the mechanical lift and had skin tears. Physician B said that the skin tears were very extensive and he referred Resident #1 to an outside wound care clinic for treatment. Resident # 3 In an observation on 6/13/14 on 1:01 p.m., revealed Resident #3 being transferred via mechanical lift by CNA N and CNA O. Resident #3 slings was hooked onto the mechanical lift, the legs of the mechanical lift were opened and remained opened until after Resident #3 was lifted from her geri-chair via mechanical lift, the mechanical lift legs closed on their own. CNA N and CNA O continued to transfer Resident #3 to her bed with the mechanical lift legs closed. In an interview on 6/13/14 at 1:01 p.m., CNA N said he was aware that mechanical lift legs closed before sliding it underneath Resident #3's bed. He said the legs on the mechanical lift close all of the time because the bar in the back to lock in the legs did not work. He said he had told the ADON about the legs not locking about a couple weeks ago. CNA O showed CNA N how to lock in the handle in the back of the mechanical lift so the legs stay locked. After CNA N observed CNA O lock in the legs of the mechanical lift, he said, "Oh, I guess I did not do it right." Resident # 13 Record review of Resident #13's Admission Record Sheet, undated, revealed Resident #13 was a [AGE] year old female admitted to the facility initially on 08/02/213 and her [DIAGNOSES REDACTED]. Record review of Resident #13's admission orders [REDACTED] Record review of Resident #13's Admission/Readmission Data Collection Tool, dated 06/13/14, revealed Resident #13 was identified as requiring extensive assist-assist of 2 with transfers (mechanical lift is not an option available on the form) and toileting. Resident #13 is also identified as having impairment on both sides of her lower extremity that interferes with daily functions or places the resident at risk of injury. Resident #13's balance is described as not steady and only able to stabilize with human assistance. Resident # 13 indicates she has had frequent pain in the last five days that has made it hard for her to sleep at night and limited her day to day activities. Resident #13 identified her pain level in the last five days as a 7 on a scale of 1 to 10. Resident #13 is described as not having any observable or documented signs of pain, but is also identified as having pain present in her back and joints (The resident's ankle fracture is not identified as a source of pain specifically) Record review of Resident #13's Interim Plan of Care, dated 06/13/14, revealed resident is identified as having frequent pain in right ankle, pressure sore, oxygen per nasal cannulas, fall risk, and at risk for infection. No method of transfer or level of required assistance with transfers was identified. Record review of Resident #13's Plan of Care, undated, identifies Resident #13 as having problems in the area of ADL functional/rehabilitation potential and requiring assistance with ADLS due to right tibia/fibula fracture. The Plan of Care was edited on 06/17/14 by LVN D. The approach date for the transfer intervention is identified as 06/14/14. The Plan of Care identifies Resident #13 as requiring assist of 2 with Hoyer and non-weight bearing status. The approach start dates for bathing, bed mobility, dressing, and toileting are 08/30/13 and identifies Resident #13 as requiring the assist of one in these areas. Record review of Resident #13's clinical record revealed the following entries in the nurse's notes: 06/05/14 9:45 AM Resident complained of generalized discomfort but has ROM (range of motion). . . Resident has generalized edema to bilateral lower feet, ankles, and legs, bruising starting to form to right ankle. Physician A notified of fall, no new orders received. Signed by LVN A. 06/06/14 6:45 AM Resident right ankle is bruised and swollen. Resident could not bear weight on right foot. Notified Physician A and new order received to x-ray right ankle. Notified mobile x-ray and resident daughter. Signed by LVN B. 06/06/14 9:00 AM Mobile x-ray at facility. Signed by LVN B. 06/06/14 9:30 AM x-ray report received (indicating fracture of right ankle). Called Physician A cell phone and left voice mail, notified his office nurse via voice mail and faxed x-ray report to his office. Notified DON and residents daughter of x-ray results. Signed by LVN B 06/06/14 4:15 PM return from ortho appointment. New orders received. One Norco 5/325 by mouth every six hours PRN. RLE in splint, non-weight bearing right ankle, keep ankle elevated, keep splint dry, and follow up appointment in one week. Notified Physician A and resident's daughter. Signed by LVN B. 06/07/14 2:50 AM Vital signs: 140/81, 97.9, 80, 18, neuro checks WNL. Splint intact to RLE. Resident is non-weight bearing on right leg. Hoyer Lift for transfers. Denies any pain or discomfort. Record review of Resident #13's clinical record revealed a final x-ray report from mobile imaging, dated 06/06/14, for Resident #13's right ankle that provided the following impression: mildly displaced bimalleolar fracture of the right ankle. The American Academy of Orthopedic Surgeons identify an ankle fracture as when one or more of the bones that make up the ankle joint "are broken" . The Academy identify the bones of the ankle as the tibia (shinbone), fibula (smaller bone of the lower leg), and the talus (a small bone that sits between the heel bone and the tibia and fibula " . The Academy identifies a bimalleolar fracture as when the " tibia and fibula are broken ". http://orthoinfo.aaos.org/topic.cfm?topic=a Record Review of Resident #13's clinical record revealed a Resident Transfer Form, undated, which indicated Resident #13 was transferred to the local emergency room . The form revealed Resident #13 experienced a fracture of the Right Lower Extremity on 06/06/14 and was non-weight bearing. The form revealed Resident #13's had a blood pressure of 90/40 (systolic/diastolic), a temperature of 99.9, and an oxygen saturation level of 79%. In an interview on 06/12/14 at 8:35 AM the DON stated that Resident #13 was a one-person transfer prior to her fall but due to her non-weight bearing status, her method of transfer had been changed. Record review of Resident #13's medical records from local hospital revealed an x-ray result of Resident #13's right ankle, dated 06/10/14, that describes the following findings "an oblique fracture through the distal fibular diaphysis demonstrates one-quarter shaft width of lateral subluxation of the distal fragment. A transverse fracture through the medial malleolus demonstrates mild lateral subluxation. An oblique fracture through the anterior aspect of the tibial plafond appears to be present, although partially obscured by splint artifact." The American Academy of Orthopedic Surgeons provides the following definitions: oblique fracture: This type of fracture has an angled pattern and is typically unstable. distal: Location in an extremity ....farther from the midline or from the point of reference fibular diaphysis: long, straight, cylindrical mid-portion of the fibula lateral: Lying away from the midline subluxation: An incomplete disruption in the relationship of two bones forming a joint, ie, a partial dislocation. The joint surfaces retain partial contact. transverse fracture: A fracture in which the fracture line is perpendicular to the shaft of the bone Medial malleolus - inside part of the tibia Anterior-Surface at the front of the body, facing the examiner Orthoanswers defines a tibial plafond fracture as a fracture that "occurs at the bottom of the shin bone (tibia), and involves the ankle joint. http://www.orthoanswer.org/foot-ankle/fracture-pilon/definition.html Record review of Resident #13's clinical record revealed a nurses' note, dated 06/13/14 at 4:20 PM, that stated, "Res (Resident) arrived to facility from (local hospital), res A&O (alert and oriented) x 2, Res is pleasant, escorted by family, res has multiple bruises BUE's, has edema all over body, respers (resperations) even non labored, 0 c/o (complaints of) @ (at) this time, 0 s/sx (signs/symptoms) of acute distress, has splint on RLE that goes from foot to knee". In an interview on 06/14/14 at 9:10 AM LVN D stated that Resident #13 returned to the facility yesterday and was being sent back to the hospital due to her foot being at an odd angle. Observation on 06/14/14 at 9:10 AM of Resident #13 revealed the resident lying on her back with her right knee facing toward the ceiling. The resident right leg was observed to be in a cast below the knee and her right foot was observed to be laying on its right side with the toes facing to the right, away from the resident and toward the wall. In an interview on 06/14/14 at 9:17 AM Physician A stated he was sending Resident #13 to the hospital because he believed the cast is causing the fracture to shift. In an interview on 06/14/14 at 9:20 AM LVN D stated Resident #13's foot was noticed to be at an odd angle after she was toileted by CNA's this morning. In an interview on 06/14/14 at 9:27 AM CNA F stated that she toileted Resident #13 this morning (06/14/14) based on the instructions of the ADON. CNA F stated the ADON told her to transfer Resident #13 using two people. CNA F stated that she told the ADON she was concerned about trying to transfer the resident before attempting the transfer. CNA F stated that she and CNA B transferred the resident from the bed to the wheelchair and then to the toilet in the restroom. CNA F stated after the resident used the restroom they transferred the resident from the toilet to the wheelchair and then back to the bed. CNA F stated they tried to keep the resident from bearing weight on her leg because she was non weight bearing, but the foot did sit on the floor when the resident was on the toilet. CNA F stated that after the resident was back in bed RN A came in to the room and noticed the resident's right foot was at an odd angle. CNA F stated that the doctor was already in the building when this occurred and he was not contacted specifically regarding this incident. CNA F stated the aides were running behind schedule this morning due to there being only one aide last night. CNA F stated that she was feeding the last person in the dining room when the ADON came to her and said to toilet Resident #13. CNA F stated the ADON told her the resident would be a two person transfer because she was non-weight bearing. CNA F stated at that point CNA G interrupted the conversation and said they needed to use a bedpan for Resident #13 because she was non-weight bearing. CNA F reported the ADON "just rolled her eyes" at CNA G's comment. CNA F admitted she was concerned about transferring the resident so she asked LVN D, the charge nurse, if she should follow the directions of the ADON or the recommendation of CNA G. CNA F stated LVN D advised her to follow the directions of the ADON. CNA F stated after RN A noticed Resident #13's foot she told the ADON the resident could not be transferred with two people. Record review of a witness statement provided by CNA F on 06/14/14 at 11:30 AM revealed CNA F made the following statement about transferring Resident #13: " I (CNA F) was helping an aide (aide's name) with her assigned residents (residents' names) to the dining room. I had gotten (resident name) to the feeder table at 8:00 AM while feeding her (ADON) came in and told me (Resident #13) need to go the toilet. I stated that I just got (resident's name) in the dining room to feed, she (ADON) stated that she would feed (resident's name). Then she went on to say that she (Resident #13) is a two person transfer and no weight bearing. My other aide (CNA G) who was helping another resident spoke out loud and said she's (Resident #13) no weight bearing and that before she (Resident #13) went to the hospital that we (facility employees) uses the bed pan. (CNA G) stated to me "I wouldn't do that (CNA F)" use the bed pan. Since I'm PRN I've never knew any conditions of (Resident #13) prior because I haven't worked with her before. I then noticed (ADON) rolling her eyes in the air. To me that look said you need to do what I say. So being unsure what to do, because I didn't feel comfortable on who to believe. So I told (ADON) that it will be hard to get an aide right now because we are behind and everyone is tending to their resident. She said well she has to go to the bathroom. So as I headed out the dining room, I stop at the nurse (LVN D) and told him what was just stated in the dining room between (ADON), myself, and CNA G. I said to (LVN D) also I'm in a tight situation. I agree with (CNA G), but I have to listen to (ADON). He advised me "yes" listen to (ADON). So I made my way to Resident #13's room and got there and went to (resident's name) next door to find some assistance. I was able to get CNA B. I told her what was said in the dining room and what LVN D said. So she said ok I'll help you. CNA B grabbed the pink gait belt that says (Resident #13's name). She got the gait belt on good and secure. I got the chair on her (Resident #13) left side. We both kept make sure to each other if the gait belt felt secure enough to lift her so that we can make sure that her right leg didn't touch the floor. We was able to do a secure transfer but it was very difficult because of space, strength, and trying to keep eye on the bad leg. (When) she was in the chair I wheeled her into the bathroom of her room and me and CNA B used to the same technique we used to transfer to toilet, but once on the toilet we noticed she wasn't all the way back on the toilet. So I got behind (Resident #13) to take control of the upper body and (LVN B) grabbed the bottom thigh area to try and get her further back, but before we made the adjustment we noticed that her feet was touching the floor like height wise. Once we got her further back she was able to urinate. We both said to each other that we gonna have to do this same technique to get her back in the chair to keep the foot from bearing weight. We did that. Again it was hard, difficult and we both felt uncomfortable having to this. We got her back in her chair and transferred her back to bed. As we were talking to each other (RN A) came into the room, and assisted with the pillow to put under her legs. I held the legs up she (RN A) put pillow under. She then asked us if her foot looked like that before we transferred her. We said no. (It) looked a little more twisted. I told her what was said in the dining room and that I had asked LVN D what I should do and that I was just doing what I was instructed to do and that I didn't believe we should have transferred her. She said right! As me and (CNA B left the room I walked to the nurses' station where (ADON was I stated to her I don't think we need to do that again because it's hard for (Resident #13) and us (aides). She told me then well next time we will just use the hoyer and sit her on the bedside commode. I said to her I think we should use the bed pan. (ADON) said no she can't use the bed pan we just need to get her up. (RN A) I believe overheard (ADON) and stated out loud "she's no weight bearing" and it is a safety issue. (ADON) again rolled her eyes up in the air and said "We will use the hoyer next to put her (Resident #13) on the bedside commode." Record review of a witness statement provided by CNA G on 06/14/14 at 11:10 p.m. revealed CNA G made the following statement about the ADON instructions for transferring Resident #13 on 06/14/14: I, (CNA G), was assisting a resident in the dining room with coffee. While in the dining room I saw the ADON go to the feeding table where (CNA F) was feeding a resident during that time. (ADON) stated to (CNA F) that Resident #13 needed to go to the bathroom. (CNA F) stated that she was feeding a resident. ADON stated that, "Well," Resident #13 "has to go to the bathroom." That is when I stated to (ADON) that before Resident #13 went to the hospital she was using the bedpan. (ADON) ignored me and told (CNA F) she neede

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures for abuse prevention for two of eight residents (Resident #1 and #4) reviewed involved in possible incidents of abuse as evidenced by: On 05/15/14 Resident # 1 ' s family member reported to facility staff that LVN I told Resident # 1 that her son was relinquishing guardianship of her because he " hated her " . The facility identified this as a grievance and did not investigate the allegation or report the allegation to the state due to their belief that the allegation was a result of the resident ' s " anxiety " and " paranoid " behavior. On 05/14/14 Resident # 4 sustained an injury to her forehead identified after receiving care from CNA E and CNA H. Due to Resident # 4 ' s combative behavior it was assumed the injury was sustained during a transfer via a mechanical lift by CNA E and CNA H despite the aides reporting that they did not observe the resident hit her head during the transfer. This failure could affect the two identified residents as well as the additional 21 residents identified on the facility provided CMS Form 802 as having behaviors by placing them at risk for unidentified abuse or neglect. The findings included: Record review of the facility ' s Leadership Policies and Procedures: Abuse, Neglect and Misappropriation, revised on 05/01/13, revealed " The facility ' s Leadership prohibits neglect, mental or physical abuse ... The facility ' s leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and/or funds. The facility ' s Leadership will provide notification to the proper authorities . . . The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident . . . " According to the facility ' s abuse policy " staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types of abuse include but are not limited to physical assault/abuse . . . mental abuse . . . verbal abuse . . . neglect . . . All alleged violations concerns abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator . . . and other enforcement agencies according to state law including the State Survey and Certification Agency . . . The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken . . . The investigation may include but is not limited to the following: Identification and removal of the alleged perpetrators . . .Written summaries of interviews with individuals having firsthand knowledge of the incident . . . Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer . . .In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process . . . Guidelines for Investigation: Immediately assess the resident/patient at the time of discovery of alleged abuse. Document assessment in the medical record. Maintain the resident ' s/patient ' s protection during the investigation . . . Protection: During the investigation , the facility protect the patient/resident, as appropriate, including but not limited to the following: Removal of the alleged abuser from the patient/resident care setting. Enforcing a zero tolerance standard for retaliation against the alleged victim. " Resident #1 Record review of Resident #1 ' s Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 5/23/14 at 4:00 p.m., Resident #1 stated her son was trying to get her another guardian because he did not understand all the medical stuff that was going with her. Resident #1 stated about 3-4 weeks ago LVN I told Resident #1 that her son hated her and this was the reason why Resident #1 ' s son was given up guardianship over her. Resident #1 ' s face/eyes turned red and she began crying when statement was made to surveyor. Resident #1 stated she reported it to the DON and the Administrator. Resident #1 said she also told her family member, who reported to the Administrator, Social Worker, and DON. Resident #1 said nothing was done about it, except now a different nurse takes care of her instead of LVN I. In an interview with Resident #1 ' s Family Member on 05/23/14 at 4:30 PM he/she stated he/she had been told by Resident #1 that LVN I told Resident #1 her son was giving up guardianship of her because he " hated her " . The family member stated this occurred around May 11, 2014. The family member stated Resident #1 was very upset and crying when she relayed the incident. The family member stated he/she reported to staff because it was so upsetting. The family member stated that after that incident Resident #1 became " scared " of LVN I. The family member stated that Resident #1 has now been assigned a new nurse and is no longer being cared for by LVN I. The family member stated that he/she feels better about the situation now that Resident #1 is no longer under the care of LVN I. In an interview with the Administrator on 05/23/2014 at 5:05 PM she stated she was aware of the incident involving Resident #1 and LVN I. The Administrator stated that Resident #1 told her son that LVN I had said the son was giving up guardianship of Resident #1 because he " hated her " . The Administrator described Resident #1 as " delusional " and stated that Resident #1 makes " all kinds " of allegations. The Administrator stated that she did not report the allegation because she did not think it was valid. In an interview with the DON on 05/23/2014 at 5:15 PM she stated was aware of the incident involving Resident #1 and LVN I. The DON stated that she had spoken with LVN I who denied making such a statement to Resident #1. The DON described Resident #1 as " paranoid " and stated that she asked Resident #1 if maybe she misconstrued comments made by LVN I. The DON stated she did not feel like the situation required reporting because Resident #1 routinely made accusation against staff and was care planned for that behavior. The DON stated they knew Resident #1 so were not concerned about the possibility of abuse. In an interview with the ADON on 05/23/14 at 5:20 PM she stated that she had spoken with Resident #1 and did not feel the accusations met the level of abuse due to the resident having a history of making accusations against staff. The ADON stated she spoke with Resident #1 who agreed she may have misunderstood LVN I ' s statement. In an interview with the Social Worker on 05/27/14 at 10:40 AM she stated she conducted the initial investigation of the incident involving Resident #1. The Social Worker stated that Resident #1 ' s family member filed a grievance with her regarding a statement made to Resident #1 by LVN I. The Social Worker stated that she then spoke to Resident #1 and the family member. The Social Worker stated that Resident #1 told her that LVN I had said her son hated her. The Social Worker described Resident #1 as " crying " and " upset " during the conversation, but stated Resident #1 calmed down. The Social Worker stated that she did not speak LVN I, but gave the grievance to nursing management since the allegation was against a nurse. The Social Worker stated she did not have concerns about it being abuse because Resident #1 has a history of making " anxious complaints " about staff. The Social Worker stated that Resident #1 did not claim it was abuse, just stated that it " hurt her feelings " . The Social Worker stated that she had no further involvement in the investigation after it was turned over to nursing management. In an interview on 05/27/14 at 2:45 PM LVN I stated that she was not aware of the grievance involving Resident #1 until Thursday, 05/22/14. LVN I stated that the DON asked her on 05/22/14 if she had ever said anything about Resident #1 ' s son hating her. LVN I stated she denied ever making such a statement about Resident #1 or her son. LVN I denied ever speaking to the ADON about the incident or the Social Worker. LVN I stated that she never received a specific in-service regarding customer service or attitude. LVN I stated that all staff did an in-service on treatment of [REDACTED]. LVN I stated that she was caring for Resident #1 until 05/22/14 when another nurse was assigned to Resident #1. LVN I stated that she did speak with Resident #1 about her son relinquishing guardianship because Resident #1 was very upset about the situation. LVN I stated she was passing medications to Resident #1 when the resident began to cry. LVN I stated she asked Resident #1 what was wrong and the resident told her about her son relinquishing guardianship. LVN I stated that she told Resident #1 everything would be okay and that their relationship would improve because he could just be her son. Record review of Resident #1 ' s Minimum Data Set (MDS)-Quarterly Resident Assessment and Care Screening, dated 04/28/14, reflected Resident #1 ' s Brief Interview for Mental Status (BIMS) score as 15, indicating the resident is cognitively intact. The MDS reflected a Patient Health Questionnaire (PHQ-9) score of nine (9) indicating the resident was experiencing mild depression. The MDS also indicated no evidence of behavior, including physical or verbal directed toward others or rejection of evaluation or care. The MDS reflected the resident received antidepressant medications, but no anti-psychotics or anti-anxiety medication. Record review of the facility ' s Complaint/Grievance Report reflected the incident involving Resident # 1 and LVN I was communicated to the facility on [DATE]. The report indicates the complaint/grievances was communicated verbally to the Social Worker by Resident #1 ' s Family Member. The report described the grievance as Resident #1 reporting LVN I told her that her son was giving up guardianship because her son " hates her " . Resident #1 also reported via the Family Member that she receives more medications when LVN I works than when other nurses work. The report indicates the grievance was assigned to the ADON on 05/19/14 and the plan to resolve the complaint was to conduct customer service in-service with the nurse. The report indicates the ADON spoke to Resident #1 who agreed she would try not to get so upset and that there was just a lot going on in her life. The report reflected a statement by Resident #1 that she would just wipe the slate clean and start all over with LVN I. The report was signed by the Social Worker on 05/15/14 and the ADON on 05/19/14. Resident #4 Record review of Resident #4 ' s Admission Record sheet, undated, revealed Resident #4 is an [AGE] year old female , admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In an observation on 5/23/14 at 11:05 a.m., revealed Resident #4 was in her room, lying on her bed with a large purple-yellowish bruise covering her right forehead above the eyebrow, the right side of her face, and the right side of her neck. In an observation on 05/27/14 at 3:20 PM, Resident #4 was observed being transferred via mechanical lift by CNA C and CNA D from her bed to a geri-chair. Resident #4 was calm and displayed no combative behaviors during the transfer. Resident #4 was observed to require assistance in sitting up and did not come close enough to the frame of the mechanical lift during the transfer to hit her head. During this observation CNA C stated that Resident #4 does have a history of being combative during incontinent care, but not necessarily while being transferred via the mechanical lift. In an interview on 5/23/14 at 11:58 a.m., the DON stated Resident # 4 was combative with transfers and pericare. The DON stated she had spoken to the CNA E and CNA G when Resident #4 sustained the injury to her head on 05/14/14 while receiving care and an incident report was filled out. In an interview on 5/23/14 at 12:10 p.m., CNA E stated she was providing care to Resident #4 on 05/15/14 when the injury to Resident #4 ' s forehead was identified. CNA E stated she did not know whether Resident #4 became scared during care in the mornings. CNA E said Resident # 4 ' s head hit the lift when her and CNA G were hooking the sling to the Mechanical lift. CNA E said she did not hear Resident #4 ' s head hitting the lift. CNA E stated Resident #4 ' s forehead was noted to have a bump without bruising or redness after Resident #4 had been transferred to her chair. CNA E stated the DON spoke with her about the incident, but she was never asked to write a statement. In an interview with the DON on 05/23/2014 at 1:25 PM she stated she was aware of the staff having issues with Resident #4 during care and transfer. The DON stated Resident #4 could be combative. The DON stated that the incident involving Resident #4 was not reported because it was assumed the injury occurred during transfer via a mechanical lift due to the resident ' s history of combativeness during care. In an interview with CNA H on 05/27/14 at 11:15 she stated she was present on 05/15/14 when the injury to Resident #4 ' s forehead was identified. CNA H stated that she was asked by CNA E to assist in providing Resident #4 incontinent care and transferring her. CNA H stated that while rolling Resident #4 toward her during incontinent care she noticed a knot on Resident #4 ' s head. CNA H stated that Resident #4 is often combative during care, but was not combative during this incident. CNA H denied seeing Resident #4 hit her head at point while providing care. CNA H stated that they completed incontinent care and notified the ADON and DON prior to transferring Resident #4 via a mechanical lift. CNA H stated the DON and ADON asked her and CNA E what happened. CNA H stated that she told the ADON and DON she did not know how the injury occurred. CNA H stated that they performed the transfer via mechanical lift after the ADON and DON were notified and after the resident was assessed. CNA H stated she never completed a written statement regarding the incident. In an interview on 05/27/14 at 11:34 CNA E stated that on 05/15/14 she and CNA H noticed the injury to Resident #4 ' s forehead prior to performing a transfer via the mechanical lift. CNA E stated that she could not remember who noticed the injury or if the ADON was notified after transferring the resident via the mechanical lift. CNA E stated that she could not remember what she told the ADON and DON about the possibility of the resident having sustained the injury from the mechanical lift. CNA E stated that she did not do a written statement. CNA E confirmed that CNA H was in the room assisting her with Resident #4. CNA E stated that CNA H ' s recollection of the event is probably more accurate. CNA E stated that she was doing direct care and CNA H was observing. CNA E stated that she has difficulty recalling events. In an interview on 05/27/14 at 11:56 the ADON stated that CNA E notified her about the injury to Resident #4. The ADON stated that Resident #4 had already been transferred via the mechanical lift when she assessed the resident. The ADON stated that CNA E and CNA H told her that they did not know how the injury had occurred and they did not notice it until they transferred her to the geri-chair. The ADON stated that CNA E did not inform her that she had seen the injury prior to Resident #4 being transferred. The ADON stated that since the injury was not noticed until after a transfer with the mechanical lift it was assumed the injury occurred during the transfer. The ADON stated CNA E and CNA H both denied seeing the resident hit her head during the transfer. In an interview on 05/27/14 at 12:05 PM the DON stated that she could not remember which aide notified her of the injury to Resident #4. The DON stated one of the aides came to her office and asked her to come look at Resident #4 ' s head. The DON stated that she believes the resident was already in her geri-chair when she assessed the resident, but she is not a " one hundred percent sure " . The DON stated that there was not bruising to Resident #4 ' s head, but was just a raised area. The DON stated CNA E and CNA H told her they did not notice the injury prior to transferring the resident. The DON stated that CNA E and CNA H did not say they saw Resident #4 hit her head, but stated they did not know what had happened. The DON stated that an Investigation Worksheet had been completed and the incident documented in Resident #4 ' s nurse ' s notes, but no further documentation or statements were written regarding the incident. Record review of Resident #4 ' s clinical record revealed a nurses note dated 03/24/2014 that stated Resident #4 was combative during her shower and was attempting to hit staff. The nurse ' s note stated Resident #4 hit her left hand on the shower char causing purple bruising. The nurse ' s note further stated that Resident #4 was transferred via a Hoyer Lift. An additional nurses ' note, dated 05/14/14, stated the CNA reported to the nurse that the resident was " resistant and combative " with care during incontinent care and a transfer via the Hoyer Lift. The nurse ' s notes stated the CNA reported to the nurse that the resident had a " raised area " on her forehead which was noted to be half dollar sized. The nurse ' s note described the injury as a " round, raised area to right forehead, light purple in color " . Record review of Resident #4 ' s most recent care plan, dated 03/27/14 revealed no identification of behavioral issues. The care plan did not identify Resident #4 as having a history of or current issue with combativeness during care. Record review of Resident #4 ' s most recent MDS, dated [DATE], revealed no identification of behavioral issues. The MDS reflected Resident #4 did not exhibit physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others. Record review of the facility ' s Incident/Accident Investigation Worksheet revealed the incident involving Resident #4 occurred on 05/14/14 at 10:00 AM. The worksheet indicated the type of incident was transfer/positioning and a secondary injury of a hematoma occurred. The location of the injury was Resident #4 ' s right forehead. The worksheet indicated the physician and family were notified and an ice pack was administered. The worksheet revealed the CNA (CNA E or CNA H) reported that Resident #4 was being " very combative " during care and noted a " large raised area " to the right forehead with " light purple bruising " while using a " hoyer lift " . The Incident/Accident Investigation Findings reflected Resident #4 had a raised area to her right forehead after being combative during care. The findings reflected at the conclusion of the investigation on 05/15/14 Resident #4 had no swelling to her forehead, but had " dark purple " visible bruising above her right brow. Record review of the facility ' Form CMS-802, undated, provided by the facility upon entrance, identified 21 residents who display behavioral symptoms.

Based on observation, interview, and record review, the facility failed to ensure alleged violations of abuse were reported and investigated to the State survey and certification agency for two of eight residents (Resident #1 and #4) reviewed involved in possible incidents of abuse as evidenced by: On 05/15/14 Resident # 1 ' s family member reported to facility staff that LVN I told Resident # 1 that her son was relinquishing guardianship of her because he " hated her " . The facility identified this as a grievance and did not investigate the allegation or report the allegation to the state due to their belief that the allegation was a result of the resident ' s " anxiety " and " paranoid " behavior. On 05/14/14 Resident # 4 sustained an injury to her forehead identified after receiving care from CNA E and CNA H. Due to Resident # 4 ' s combative behavior it was assumed the injury was sustained during a transfer via a mechanical lift by CNA E and CNA H despite the aides reporting that they did not observe the resident hit her head during the transfer. This failure could affect the two identified residents as well as the additional 21 residents identified on the facility provided CMS Form 802 as having behaviors by placing them at risk for unidentified abuse or neglect. The findings included: Resident #1 Record review of Resident #1 ' s Admission Record Sheet, undated, revealed a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 5/23/14 at 4:00 p.m., Resident #1 stated her son was trying to get her another guardian because he did not understand all the medical stuff that was going with her. Resident #1 stated about 3-4 weeks ago LVN I told Resident #1 that her son hated her and this was the reason why Resident #1 ' s son was given up guardianship over her. Resident #1 ' s face/eyes turned red and she began crying when statement was made to surveyor. Resident #1 stated she reported it to the DON and the Administrator. Resident #1 said she also told her family member, who reported to the Administrator, Social Worker, and DON. Resident #1 said nothing was done about it, except now a different nurse takes care of her instead of LVN I. In an interview with Resident #1 ' s Family Member on 05/23/14 at 4:30 PM he/she stated he/she had been told by Resident #1 that LVN I told Resident #1 her son was giving up guardianship of her because he " hated her " . The family member stated this occurred around May 11, 2014. The family member stated Resident #1 was very upset and crying when she relayed the incident. The family member stated he/she reported to staff because it was so upsetting. The family member stated that after that incident Resident #1 became " scared " of LVN I. The family member stated that Resident #1 has now been assigned a new nurse and is no longer being cared for by LVN I. The family member stated that he/she feels better about the situation now that Resident #1 is no longer under the care of LVN I. In an interview with the Administrator on 05/23/2014 at 5:05 PM she stated she was aware of the incident involving Resident #1 and LVN I. The Administrator stated that Resident #1 told her son that LVN I had said the son was giving up guardianship of Resident #1 because he " hated her " . The Administrator described Resident #1 as " delusional " and stated that Resident #1 makes " all kinds " of allegations. The Administrator stated that she did not report the allegation because she did not think it was valid. In an interview with the DON on 05/23/2014 at 5:15 PM she stated was aware of the incident involving Resident #1 and LVN I. The DON stated that she had spoken with LVN I who denied making such a statement to Resident #1. The DON described Resident #1 as " paranoid " and stated that she asked Resident #1 if maybe she misconstrued comments made by LVN I. The DON stated she did not feel like the situation required reporting because Resident #1 routinely made accusation against staff and was care planned for that behavior. The DON stated they knew Resident #1 so were not concerned about the possibility of abuse. In an interview with the ADON on 05/23/14 at 5:20 PM she stated that she had spoken with Resident #1 and did not feel the accusations met the level of abuse due to the resident having a history of making accusations against staff. The ADON stated she spoke with Resident #1 who agreed she may have misunderstood LVN I ' s statement. In an interview with the Social Worker on 05/27/14 at 10:40 AM she stated she conducted the initial investigation of the incident involving Resident #1. The Social Worker stated that Resident #1 ' s family member filed a grievance with her regarding a statement made to Resident #1 by LVN I. The Social Worker stated that she then spoke to Resident #1 and the family member. The Social Worker stated that Resident #1 told her that LVN I had said her son hated her. The Social Worker described Resident #1 as " crying " and " upset " during the conversation, but stated Resident #1 calmed down. The Social Worker stated that she did not speak LVN I, but gave the grievance to nursing management since the allegation was against a nurse. The Social Worker stated she did not have concerns about it being abuse because Resident #1 has a history of making " anxious complaints " about staff. The Social Worker stated that Resident #1 did not claim it was abuse, just stated that it " hurt her feelings " . The Social Worker stated that she had no further involvement in the investigation after it was turned over to nursing management. In an interview on 05/27/14 at 2:45 PM LVN I stated that she was not aware of the grievance involving Resident #1 until Thursday, 05/22/14. LVN I stated that the DON asked her on 05/22/14 if she had ever said anything about Resident #1 ' s son hating her. LVN I stated she denied ever making such a statement about Resident #1 or her son. LVN I denied ever speaking to the ADON about the incident or the Social Worker. LVN I stated that she never received a specific in-service regarding customer service or attitude. LVN I stated that all staff did an in-service on treatment of [REDACTED]. LVN I stated that she was caring for Resident #1 until 05/22/14 when another nurse was assigned to Resident #1. LVN I stated that she did speak with Resident #1 about her son relinquishing guardianship because Resident #1 was very upset about the situation. LVN I stated she was passing medications to Resident #1 when the resident began to cry. LVN I stated she asked Resident #1 what was wrong and the resident told her about her son relinquishing guardianship. LVN I stated that she told Resident #1 everything would be okay and that their relationship would improve because he could just be her son. Record review of Resident #1 ' s Minimum Data Set (MDS)-Quarterly Resident Assessment and Care Screening, dated 04/28/14, reflected Resident #1 ' s Brief Interview for Mental Status (BIMS) score as 15, indicating the resident is cognitively intact. The MDS reflected a Patient Health Questionnaire (PHQ-9) score of nine (9) indicating the resident was experiencing mild depression. The MDS also indicated no evidence of behavior, including physical or verbal directed toward others or rejection of evaluation or care. The MDS reflected the resident received antidepressant medications, but no anti-psychotics or anti-anxiety medication. Record review of the facility ' s Complaint/Grievance Report reflected the incident involving Resident # 1 and LVN I was communicated to the facility on [DATE]. The report indicates the complaint/grievances was communicated verbally to the Social Worker by Resident #1 ' s Family Member. The report described the grievance as Resident #1 reporting LVN I told her that her son was giving up guardianship because her son " hates her " . Resident #1 also reported via the Family Member that she receives more medications when LVN I works than when other nurses work. The report indicates the grievance was assigned to the ADON on 05/19/14 and the plan to resolve the complaint was to conduct customer service in-service with the nurse. The report indicates the ADON spoke to Resident #1 who agreed she would try not to get so upset and that there was just a lot going on in her life. The report reflected a statement by Resident #1 that she would just wipe the slate clean and start all over with LVN I. The report was signed by the Social Worker on 05/15/14 and the ADON on 05/19/14. Resident #4 Record review of Resident #4 ' s Admission Record sheet, undated, revealed Resident #4 is an [AGE] year old female , admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In an observation on 5/23/14 at 11:05 a.m., revealed Resident #4 was in her room, lying on her bed with a large purple-yellowish bruise covering her right forehead above the eyebrow, the right side of her face, and the right side of her neck. In an observation on 05/27/14 at 3:20 PM, Resident #4 was observed being transferred via mechanical lift by CNA C and CNA D from her bed to a geri-chair. Resident #4 was calm and displayed no combative behaviors during the transfer. Resident #4 was observed to require assistance in sitting up and did not come close enough to the frame of the mechanical lift during the transfer to hit her head. During this observation CNA C stated that Resident #4 does have a history of being combative during incontinent care, but not necessarily while being transferred via the mechanical lift. In an interview on 5/23/14 at 11:58 a.m., the DON stated Resident # 4 was combative with transfers and pericare. The DON stated she had spoken to the CNA E and CNA G when Resident #4 sustained the injury to her head on 05/14/14 while receiving care and an incident report was filled out. In an interview on 5/23/14 at 12:10 p.m., CNA E stated she was providing care to Resident #4 on 05/15/14 when the injury to Resident #4 ' s forehead was identified. CNA E stated she did not know whether Resident #4 became scared during care in the mornings. CNA E said Resident # 4 ' s head hit the lift when her and CNA G were hooking the sling to the Mechanical lift. CNA E said she did not hear Resident #4 ' s head hitting the lift. CNA E stated Resident #4 ' s forehead was noted to have a bump without bruising or redness after Resident #4 had been transferred to her chair. CNA E stated the DON spoke with her about the incident, but she was never asked to write a statement. In an interview with the DON on 05/23/2014 at 1:25 PM she stated she was aware of the staff having issues with Resident #4 during care and transfer. The DON stated Resident #4 could be combative. The DON stated that the incident involving Resident #4 was not reported because it was assumed the injury occurred during transfer via a mechanical lift due to the resident ' s history of combativeness during care. In an interview with CNA H on 05/27/14 at 11:15 she stated she was present on 05/15/14 when the injury to Resident #4 ' s forehead was identified. CNA H stated that she was asked by CNA E to assist in providing Resident #4 incontinent care and transferring her. CNA H stated that while rolling Resident #4 toward her during incontinent care she noticed a knot on Resident #4 ' s head. CNA H stated that Resident #4 is often combative during care, but was not combative during this incident. CNA H denied seeing Resident #4 hit her head at point while providing care. CNA H stated that they completed incontinent care and notified the ADON and DON prior to transferring Resident #4 via a mechanical lift. CNA H stated the DON and ADON asked her and CNA E what happened. CNA H stated that she told the ADON and DON she did not know how the injury occurred. CNA H stated that they performed the transfer via mechanical lift after the ADON and DON were notified and after the resident was assessed. CNA H stated she never completed a written statement regarding the incident. In an interview on 05/27/14 at 11:34 CNA E stated that on 05/15/14 she and CNA H noticed the injury to Resident #4 ' s forehead prior to performing a transfer via the mechanical lift. CNA E stated that she could not remember who noticed the injury or if the ADON was notified after transferring the resident via the mechanical lift. CNA E stated that she could not remember what she told the ADON and DON about the possibility of the resident having sustained the injury from the mechanical lift. CNA E stated that she did not do a written statement. CNA E confirmed that CNA H was in the room assisting her with Resident #4. CNA E stated that CNA H ' s recollection of the event is probably more accurate. CNA E stated that she was doing direct care and CNA H was observing. CNA E stated that she has difficulty recalling events. In an interview on 05/27/14 at 11:56 the ADON stated that CNA E notified her about the injury to Resident #4. The ADON stated that Resident #4 had already been transferred via the mechanical lift when she assessed the resident. The ADON stated that CNA E and CNA H told her that they did not know how the injury had occurred and they did not notice it until they transferred her to the geri-chair. The ADON stated that CNA E did not inform her that she had seen the injury prior to Resident #4 being transferred. The ADON stated that since the injury was not noticed until after a transfer with the mechanical lift it was assumed the injury occurred during the transfer. The ADON stated CNA E and CNA H both denied seeing the resident hit her head during the transfer. In an interview on 05/27/14 at 12:05 PM the DON stated that she could not remember which aide notified her of the injury to Resident #4. The DON stated one of the aides came to her office and asked her to come look at Resident #4 ' s head. The DON stated that she believes the resident was already in her geri-chair when she assessed the resident, but she is not a " one hundred percent sure " . The DON stated that there was not bruising to Resident #4 ' s head, but was just a raised area. The DON stated CNA E and CNA H told her they did not notice the injury prior to transferring the resident. The DON stated that CNA E and CNA H did not say they saw Resident #4 hit her head, but stated they did not know what had happened. The DON stated that an Investigation Worksheet had been completed and the incident documented in Resident #4 ' s nurse ' s notes, but no further documentation or statements were written regarding the incident. Record review of Resident #4 ' s clinical record revealed a nurses note dated 03/24/2014 that stated Resident #4 was combative during her shower and was attempting to hit staff. The nurse ' s note stated Resident #4 hit her left hand on the shower char causing purple bruising. The nurse ' s note further stated that Resident #4 was transferred via a Hoyer Lift. An additional nurses ' note, dated 05/14/14, stated the CNA reported to the nurse that the resident was " resistant and combative " with care during incontinent care and a transfer via the Hoyer Lift. The nurse ' s notes stated the CNA reported to the nurse that the resident had a " raised area " on her forehead which was noted to be half dollar sized. The nurse ' s note described the injury as a " round, raised area to right forehead, light purple in color " . Record review of Resident #4 ' s most recent care plan, dated 03/27/14 revealed no identification of behavioral issues. The care plan did not identify Resident #4 as having a history of or current issue with combativeness during care. Record review of Resident #4 ' s most recent MDS, dated [DATE], revealed no identification of behavioral issues. The MDS reflected Resident #4 did not exhibit physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others. Record review of the facility ' s Incident/Accident Investigation Worksheet revealed the incident involving Resident #4 occurred on 05/14/14 at 10:00 AM. The worksheet indicated the type of incident was transfer/positioning and a secondary injury of a hematoma occurred. The location of the injury was Resident #4 ' s right forehead. The worksheet indicated the physician and family were notified and an ice pack was administered. The worksheet revealed the CNA (CNA E or CNA H) reported that Resident #4 was being " very combative " during care and noted a " large raised area " to the right forehead with " light purple bruising " while using a " hoyer lift " . The Incident/Accident Investigation Findings reflected Resident #4 had a raised area to her right forehead after being combative during care. The findings reflected at the conclusion of the investigation on 05/15/14 Resident #4 had no swelling to her forehead, but had " dark purple " visible bruising above her right brow. Record review of the facility ' s Leadership Policies and Procedures: Abuse, Neglect and Misappropriation, revised on 05/01/13, revealed " The facility ' s Leadership prohibits neglect, mental or physical abuse ... The facility ' s leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect, or misappropriation of property and/or funds. The facility ' s Leadership will provide notification to the proper authorities . . . The facility ' s Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident . . . " According to the facility ' s abuse policy " staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types of abuse include but are not limited to physical assault/abuse . . . mental abuse . . . verbal abuse . . . neglect . . . All alleged violations concerns abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator . . . and other enforcement agencies according to state law including the State Survey and Certification Agency . . . The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken . . . The investigation may include but is not limited to the following: Identification and removal of the alleged perpetrators . . .Written summaries of interviews with individuals having firsthand knowledge of the incident . . . Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer . . .In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process . . . Guidelines for Investigation: Immediately assess the resident/patient at the time of discovery of alleged abuse. Document assessment in the medical record. Maintain the resident ' s/patient ' s protection during the investigation . . . Protection: During the investigation , the facility protect the patient/resident, as appropriate, including but not limited to the following: Removal of the alleged abuser from the patient/resident care setting. Enforcing a zero tolerance standard for retaliation against the alleged victim. " Record review of the facility ' Form CMS-802, undated, provided by the facility upon entrance, identified 21 residents who display behavioral symptoms.

Based on observation, interview and record review the facility failed to implement their policy to prevent neglect of 1 of 12 Residents (Resident # 1) reviewed for neglect. When Resident #1 was found unresponsive without a pulse or spontaneous respirations on [DATE], LVN A notified his family prior to calling 911, delaying emergency response measures. LVN B failed to perform effective CPR, performing compressions while the resident was on an air mattress in bed. Nursing staff failed to locate necessary supplies in a timely manner to conduct the code. Resident #1 was transported to a local hospital where he was pronounced dead [DATE] at 2:26 a.m. This was determined to be Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at isolated actual harm that is not an IJ because the facility administrative staff had not had time to implement policies and procedures and monitor the effectiveness of training outlined in their Plan of Removal. This failure could affect any of the 32 residents in the facility with physician orders [REDACTED]. The findings include: Review of Resident # 1's Physician order [REDACTED]. His [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS dated [DATE] revealed he had clear speech, was able to understand others and could make himself understood. Review of Resident #1's Annual MDS dated [DATE] revealed he scored a 15 (the highest score possible for cognition) on his BIMS, and he was always incontinent of bowel and bladder. His Active [DIAGNOSES REDACTED]. He used oxygen and received [MEDICAL TREATMENT], and he received insulin injections each of the seven prior days. Review of Resident #1's Care Plan dated [DATE] revealed " ...Full Code..." Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Nurse's Notes dated [DATE] at 2:00 a.m. revealed, "Cked (checked) on res (resident)- res (resident) not breathing- checked for pulse- cold to touch- CPR initiated with another LVN- back board in place- HOB down- Called 911. " In an interview on [DATE] at 5:55 a.m. CNA A stated "a little before 2:00 a.m." LVN A came out of Resident #1's room calling for help, at that time CNA A stated that LVN #A called on her personal cell phone with LVN A's spouse (who was the son of Resident #1 and LVN A's spouse) and was talking to him on the telephone and did not call 911 until after speaking with her spouse. In a written statement by CNA A [DATE] at 4:50 p.m., she wrote at 2:00 a.m. LVN A shouted she needed help because Resident #1 wasn't breathing. LVN B, CNA C and CNA A ran down the hall and LVN A was shaking Resident #1 saying "Pops, wake up ". LVN A then left the room and LVN B told CNA A to get the crash cart. LVN B searched in the crash cart for a mouth piece (for the ambu bag) but couldn't find one. CNA A told CNA B to get the blood pressure cuff and O2 (oxygen) reader since they were not on the crash cart. LVN A was on her cell phone, calling her husband prior to calling 911. LVN B got the CPR board, put it on the floor along with a blanket, and then put it under Resident #1 while in bed which has an air mattress on. CNA C came back with the blood pressure cuff and O2 reader. LVN B yelled at CNA A to check Resident #1's code status. LVN A came in the room and said he was a full code. LVN B put the O2 reader on his finger but nothing was reading so LVN A and LVN B started to perform CPR. They grabbed an ambu bag but there was no mouth piece. LVN A was blowing air without a mouthpiece into Resident #1's mouth while LVN B was doing chest compressions. LVN A left the room to go meet her husband. The paramedics arrived and took over. LVN B was very nervous and she stated that that was her first time performing CPR. In an interview on [DATE] at 6:50 a.m. LVN A stated that the facility did not have the proper equipment to run an effective code, there were no mouthpieces available for resuscitation. In an interview on [DATE] at 4:15 p.m. LVN A stated that when she went to check on Resident #1 just before 2:00 a.m. is when she found that he was not breathing and called LVN B for assistance. She stated that LVN B started chest compressions while LVN A called her spouse. In a written statement by LVN A [DATE] at 4:50 p.m., she revealed at 02:00 a.m. [DATE] she noticed Resident #1 wasn't breathing and called to LVN B for help. LVN A started CPR but stated there was no mouthpiece on the ambu bag. LVN A went to check the chart for code status, which was a Full Code. LVN A called 911 and the family, then returned to room to continue CPR. Ambulance arrived within 5 minutes. When LVN A returned to room, LVN B had the ambu mask. In an interview on [DATE] at 8:20 a.m., CNA C said that when Resident #1 went in to cardiopulmonary arrest on [DATE], LVN A called her husband before calling 911. In an interview on [DATE] at 8:15 a.m., LVN B said that LVN A called out for help from Resident #1's room around 2:00 a.m. [DATE], and told LVN B to get the crash cart. LVN B said she started CPR, but there was no mouthpiece for the ambu bag. LVN B said she put the backboard on Resident #1's air mattress overlay. LVN B said LVN A did not assist with CPR. In a written statement [DATE] at 4:25 p.m., LVN B revealed she was called by LVN A for help. LVN B went to Resident #1's room, who was unresponsive, no pulse, no spontaneous respirations. LVN B told the CNAs to get the crash cart and to check his code status. He was a full code and he was too heavy to take him down to the floor, so they used the back board and started CPR. LVN B sent CNA A to get the other crash cart because she couldn't find the face mask in the crash cart. Before she came back, LVN B found the face mask in a different bag. The first responders arrived, took over resuscitation efforts, and transported Resident #1 to a local hospital. Review of the hospital " Release Of Body " form revealed Resident #1 was pronounced dead [DATE] at 2:26 a.m. In a written statement by CNA B [DATE] at 10:20 a.m., she revealed she worked as an aide on west side with an agency nurse (LVN E). LVN E got a phone call from CNA A asking if we had any CPR mouthpieces. CNA B told LVN E to look on the crash cart. She could not find the correct piece. Both staff walked over to the east side. CNA B waited at the nurses' station while the code was in progress. LVN A's husband walked in right after the paramedics. In an interview with LVN E on [DATE] at 1:45 p.m., she revealed she was an agency nurse who worked at the facility for the first time on the night of [DATE] - [DATE]. LVN E stated she was working on the west side of the building, and received a call from the other nurses ' station asking for a "breather mask." She could not find a mask for an ambu bag on the crash cart. She ran to the east hall, and observed staff performing CPR while the resident was in bed. She told the facility staff that the resident needed to be on the floor. In an interview on [DATE] at 1:30 p.m., the DON said LVN A worked [DATE] 6:00 p.m.-6:00 a.m. [DATE] and [DATE] 6:00 p.m.-6:00 a.m. [DATE]. The DON said LVN A was an experienced nurse who had just started working at the facility [DATE].The DON said LVN A was being trained by LVN B during those two shifts. In an interview on [DATE] at 1:00 p.m., the DON said when Resident #1 was found unresponsive, staff should have responded immediately and started CPR while someone called 911. In an interview on [DATE] at 1:35 p.m., the DON said there was no orientation checklist for LVN A. The DON said she showed the licensed staff the mouthpiece for the ambu bag on [DATE]. She said the night shift was responsible for checking the crash cart each shift. The DON said CPR should be performed on a hard surface. In an interview on [DATE] at 11:17 a.m. with the first responders from the local fire department arrived before the emergency medical services. The first responder stated that there were two staff in the room, one was attempting CPR and the other was attempting to use the ambu bag. He stated that the chest compressions were ineffective because there was no depth to the compressions and the patient was lying on an air mattress instead of a rigid surface and the ambu bag was not placed properly on the patient's face. He stated that the patient's body was cool to touch and had been "down" for longer than a few minutes but not long enough for rigor to have set in. He stated that this had to have been an un-witnessed arrest despite what the nurse stated. In an interview on [DATE] at 9:30 a.m. with the local hospital Emergency Physician stated that for good effective compressions, the patient needed to be on a rigid surface, otherwise while performing chest compression on an air mattress, the chest compressions are ineffective, the entire body would have been moving with each attempted compression. Review of the facility's policy, "Emergency, (Code Blue), Initiation of" dated [DATE] revealed, "...Follow practice guidelines for CPR (cardiopulmonary resuscitation) by initiating "Resuscitation with and without Automatic External Defibrillator (AED), as appropriate, etc. in accordance with patient/resident Advance Directives ...Call 911 for emergency transfer to an acute care center ...Contact patient/resident's physician for further orders ...Contact patient/resident's responsible party ...Continue CPR efforts as appropriate..." "...The depth of compressions should be at least 2 inches - remember: 2 hands, 2 inches. Count aloud as you compress 30 times at the rate of about 3 compressions for every 2 seconds or approximately 100. Put the person on his or her back on a firm surface..." www.cprandfirstaid.com Review of the facility's policy, "Emergency-911" dated [DATE] revealed, "The staff will call 911 for emergency situations ...Qualified staff initiated the appropriate emergency procedures, i.e., oxygen, suction, CPR ...Call 911 when the patient's/resident's condition is life threatening ...Qualified staff attempts to stabilize and monitor the patient/resident until the advance medical team arrives..." This was determined to be Immediate Jeopardy (IJ) on [DATE] at 1:20 p.m. and the DON was informed at that time. The following Plan of Removal for the Immediate Jeopardy was submitted by the facility [DATE]: Issue(s) Identified: 1. Proper equipment on emergency cart 2. Improper code ... Re-education was started immediately with current staff in the facility: 1. Proper equipment on the emergency cart: ? The emergency carts are stocked with the proper equipment. [DATE]. Because we are a medical based institution we are required by law to have an Emergency Cart supplied with the following: (items listed per drawer) ? The emergency carts are being checked each night by the night shift nurses to validate the emergency cart is properly stocked with recommended supplies. [DATE] ? The emergency cart will be re-stocked immediately after each code, by charge nurse that called the code. Nursing management will monitor to validate compliance. ? Licensed staff has been re-educated on emergency cart, that equipment list must match supplies in emergency cart, emergency cart will be restocked by charge nurse that called the code and night shift will check each night. Staff that has not been educated will be required to have the re-education prior to working at the facility. [DATE] ? Licensed staff will be educated on the emergency cart upon hire and annually. ? The Quality Assurance Performance Improvement Committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. 2. Improper code: ? Licensed staff has been re-educated on Code Blue policy and procedure. (attached) [DATE] ? Licensed staff has completed return demonstration on proper CPR (cardiopulmonary resuscitation) [DATE] ? Licensed staff that has not been educated will be required to have the re-education prior to working at the facility. ? Licensed will be educated on the performing proper code with return demonstration upon hire and annually. [DATE] ? The Quality Assurance Performance Improvement Committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. Review of in-service sign-in sheets revealed that the in-services were given to all licensed staff by the facility's staff development coordinator between [DATE] and [DATE]. Review of the crash cart monitoring logs revealed signatures by night shift staff beginning [DATE]. Interviews with licensed staff between [DATE] and [DATE] revealed their ability to state what equipment was on the crash cart, correct procedures for CPR and measures to be taken for signs and symptoms of [DIAGNOSES REDACTED]. On [DATE] at 11:05 a.m., the DON, the Corporate RN, and the Administrator were informed the IJ was lifted. While the IJ was removed, the facility remained out of compliance at a level of isolated actual harm that is not an IJ because the facility administrative staff had not had time to implement policies and procedures and monitor the effectiveness of training outlined in their Plan of Removal. Review of the facility's list dated [DATE] of Residents requesting Full Code status revealed 32 residents.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #1) of twelve residents reviewed for neglect. The facility failed to provide appropriate resuscitative measures to Resident #1 when he suffered a cardiopulmonary arrest. When Resident #1 was found unresponsive without a pulse or spontaneous respirations on [DATE], LVN A notified his family prior to calling 911, delaying emergency response measures. LVN B failed to perform effective CPR, performing compressions while the resident was on an air mattress in bed. Nursing staff failed to locate necessary supplies in a timely manner to conduct the code. Resident #1 was transported to a local hospital where he was pronounced dead [DATE] at 2:26 a.m. This was determined to be Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a harm at a pattern that is not an IJ because the facility administrative staff had not had time to implement policies and procedures and monitor the effectiveness of training outlined in their Plan of Removal. This failure could affect any of the 32 residents in the facility with physician orders [REDACTED]. The findings include: Review of the facility's policy, "Emergency, (Code Blue), Initiation of" dated [DATE] revealed, "...Follow practice guidelines for CPR (cardiopulmonary resuscitation) by initiating "Resuscitation with and without Automatic External Defibrillator (AED), as appropriate, etc. in accordance with patient/resident Advance Directives ...Call 911 for emergency transfer to an acute care center ...Contact patient/resident's physician for further orders ...Contact patient/resident's responsible party ...Continue CPR efforts as appropriate..." "...The depth of compressions should be at least 2 inches - remember: 2 hands, 2 inches. Count aloud as you compress 30 times at the rate of about 3 compressions for every 2 seconds or approximately 100. Put the person on his or her back on a firm surface..." www.cprandfirstaid.com Review of the facility's policy, "Emergency-911" dated [DATE] revealed, "The staff will call 911 for emergency situations ...Qualified staff initiated the appropriate emergency procedures, i.e., oxygen, suction, CPR ...Call 911 when the patient's/resident's condition is life threatening ...Qualified staff attempts to stabilize and monitor the patient/resident until the advance medical team arrives..." Review of Resident # 1's Physician order [REDACTED]. His [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS dated [DATE] revealed he had clear speech, was able to understand others and could make himself understood. Review of Resident #1's Annual MDS dated [DATE] revealed he scored a 15 (the highest score possible for cognition) on his BIMS, and he was always incontinent of bowel and bladder. His Active [DIAGNOSES REDACTED]. He used oxygen and received [MEDICAL TREATMENT], and he received insulin injections each of the seven prior days. Review of Resident #1's Care Plan dated [DATE] revealed " ...Full Code..." Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Nurse's Notes dated [DATE] at 2:00 a.m. revealed, "Cked (checked) on res (resident)- res (resident) not breathing- checked for pulse- cold to touch- CPR initiated with another LVN- back board in place- HOB down- Called 911. " In an interview on [DATE] at 5:55 a.m. CNA A stated "a little before 2:00 a.m." LVN A came out of Resident #1's room calling for help, at that time CNA A stated that LVN #A called on her personal cell phone with LVN A's spouse (who was the son of Resident #1 and LVN A's spouse) and was talking to him on the telephone and did not call 911 until after speaking with her spouse. In a written statement by CNA A [DATE] at 4:50 p.m., she wrote at 2:00 a.m. LVN A shouted she needed help because Resident #1 wasn't breathing. LVN B, CNA C and CNA A ran down the hall and LVN A was shaking Resident #1 saying "Pops, wake up ". LVN A then left the room and LVN B told CNA A to get the crash cart. LVN B searched in the crash cart for a mouth piece (for the ambu bag) but couldn't find one. CNA A told CNA B to get the blood pressure cuff and O2 (oxygen) reader since they were not on the crash cart. LVN A was on her cell phone, calling her husband prior to calling 911. LVN B got the CPR board, put it on the floor along with a blanket, and then put it under Resident #1 while in bed which has an air mattress on. CNA C came back with the blood pressure cuff and O2 reader. LVN B yelled at CNA A to check Resident #1's code status. LVN A came in the room and said he was a full code. LVN B put the O2 reader on his finger but nothing was reading so LVN A and LVN B started to perform CPR. They grabbed an ambu bag but there was no mouth piece. LVN A was blowing air without a mouthpiece into Resident #1's mouth while LVN B was doing chest compressions. LVN A left the room to go meet her husband. The paramedics arrived and took over. LVN B was very nervous and she stated that that was her first time performing CPR. In an interview on [DATE] at 6:50 a.m. LVN A stated that the facility did not have the proper equipment to run an effective code, there were no mouthpieces available for resuscitation. In an interview on [DATE] at 4:15 p.m. LVN A stated that when she went to check on Resident #1 just before 2:00 a.m. is when she found that he was not breathing and called LVN B for assistance. She stated that LVN B started chest compressions while LVN A called her spouse. In a written statement by LVN A [DATE] at 4:50 p.m., she revealed at 02:00 a.m. [DATE] she noticed Resident #1 wasn't breathing and called to LVN B for help. LVN A started CPR but stated there was no mouthpiece on the ambu bag. LVN A went to check the chart for code status, which was a Full Code. LVN A called 911 and the family, then returned to room to continue CPR. Ambulance arrived within 5 minutes. When LVN A returned to room, LVN B had the ambu mask. In an interview on [DATE] at 8:20 a.m., CNA C said that when Resident #1 went in to cardiopulmonary arrest on [DATE], LVN A called her husband before calling 911. In an interview on [DATE] at 8:15 a.m., LVN B said that LVN A called out for help from Resident #1's room around 2:00 a.m. [DATE], and told LVN B to get the crash cart. LVN B said she started CPR, but there was no mouthpiece for the ambu bag. LVN B said she put the backboard on Resident #1's air mattress overlay. LVN B said LVN A did not assist with CPR. In a written statement [DATE] at 4:25 p.m., LVN B revealed she was called by LVN A for help. LVN B went to Resident #1's room, who was unresponsive, no pulse, no spontaneous respirations. LVN B told the CNAs to get the crash cart and to check his code status. He was a full code and he was too heavy to take him down to the floor, so they used the back board and started CPR. LVN B sent CNA A to get the other crash cart because she couldn't find the face mask in the crash cart. Before she came back, LVN B found the face mask in a different bag. The first responders arrived, took over resuscitation efforts, and transported Resident #1 to a local hospital. Review of the hospital " Release Of Body " form revealed Resident #1 was pronounced dead [DATE] at 2:26 a.m. In a written statement by CNA B [DATE] at 10:20 a.m., she revealed she worked as an aide on west side with an agency nurse (LVN E). LVN E got a phone call from CNA A asking if we had any CPR mouthpieces. CNA B told LVN E to look on the crash cart. She could not find the correct piece. Both staff walked over to the east side. CNA B waited at the nurses' station while the code was in progress. LVN A's husband walked in right after the paramedics. In an interview with LVN E on [DATE] at 1:45 p.m., she revealed she was an agency nurse who worked at the facility for the first time on the night of [DATE] - [DATE]. LVN E stated she was working on the west side of the building, and received a call from the other nurses ' station asking for a "breather mask." She could not find a mask for an ambu bag on the crash cart. She ran to the east hall, and observed staff performing CPR while the resident was in bed. She told the facility staff that the resident needed to be on the floor. In an interview on [DATE] at 1:30 p.m., the DON said LVN A worked [DATE] 6:00 p.m.-6:00 a.m. [DATE] and [DATE] 6:00 p.m.-6:00 a.m. [DATE]. The DON said LVN A was an experienced nurse who had just started working at the facility [DATE].The DON said LVN A was being trained by LVN B during those two shifts. In an interview on [DATE] at 1:00 p.m., the DON said when Resident #1 was found unresponsive, staff should have responded immediately and started CPR while someone called 911. In an interview on [DATE] at 1:35 p.m., the DON said there was no orientation checklist for LVN A. The DON said she showed the licensed staff the mouthpiece for the ambu bag on [DATE]. She said the night shift was responsible for checking the crash cart each shift. The DON said CPR should be performed on a hard surface. In an interview on [DATE] at 11:17 a.m. with the first responders from the local fire department arrived before the emergency medical services. The first responder stated that there were two staff in the room, one was attempting CPR and the other was attempting to use the ambu bag. He stated that the chest compressions were ineffective because there was no depth to the compressions and the patient was lying on an air mattress instead of a rigid surface and the ambu bag was not placed properly on the patient's face. He stated that the patient's body was cool to touch and had been "down" for longer than a few minutes but not long enough for rigor to have set in. He stated that this had to have been an un-witnessed arrest despite what the nurse stated. In an interview on [DATE] at 9:30 a.m. with the local hospital Emergency Physician stated that for good effective compressions, the patient needed to be on a rigid surface, otherwise while performing chest compression on an air mattress, the chest compressions are ineffective, the entire body would have been moving with each attempted compression. This was determined to be Immediate Jeopardy (IJ) on [DATE] at 1:20 p.m. and the DON was informed at that time. The following Plan of Removal for the Immediate Jeopardy was submitted by the facility [DATE]: Issue(s) Identified: 1. Proper equipment on emergency cart 2. Improper code ... Re-education was started immediately with current staff in the facility: 1. Proper equipment on the emergency cart: ? The emergency carts are stocked with the proper equipment. [DATE]. Because we are a medical based institution we are required by law to have an Emergency Cart supplied with the following: (items listed per drawer) ? The emergency carts are being checked each night by the night shift nurses to validate the emergency cart is properly stocked with recommended supplies. [DATE] ? The emergency cart will be re-stocked immediately after each code, by charge nurse that called the code. Nursing management will monitor to validate compliance. ? Licensed staff has been re-educated on emergency cart, that equipment list must match supplies in emergency cart, emergency cart will be restocked by charge nurse that called the code and night shift will check each night. Staff that has not been educated will be required to have the re-education prior to working at the facility. [DATE] ? Licensed staff will be educated on the emergency cart upon hire and annually. ? The Quality Assurance Performance Improvement Committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. 2. Improper code: ? Licensed staff has been re-educated on Code Blue policy and procedure. (attached) [DATE] ? Licensed staff has completed return demonstration on proper CPR (cardiopulmonary resuscitation) [DATE] ? Licensed staff that has not been educated will be required to have the re-education prior to working at the facility. ? Licensed will be educated on the performing proper code with return demonstration upon hire and annually. [DATE] ? The Quality Assurance Performance Improvement Committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. Review of in-service sign-in sheets revealed that the in-services were given to all licensed staff by the facility's staff development coordinator between [DATE] and [DATE]. Review of the crash cart monitoring logs revealed signatures by night shift staff beginning [DATE]. Interviews with licensed staff between [DATE] and [DATE] revealed their ability to state what equipment was on the crash cart, correct procedures for CPR and measures to be taken for signs and symptoms of [DIAGNOSES REDACTED]. On [DATE] at 11:05 a.m., the DON, the Corporate RN, and the Administrator were informed the IJ was lifted. While the IJ was removed, the facility remained out of compliance at a level of isolated actual harm that is not an IJ because the facility administrative staff had not had time to implement policies and procedures and monitor the effectiveness of training outlined in their Plan of Removal. Review of the facility's list dated [DATE] of Residents requesting Full Code status revealed 32 residents.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one of twelve residents (Resident #1) who were reviewed for quality of care. When Resident #1 was found unresponsive without a pulse or spontaneous respirations on [DATE], LVN A notified his family prior to calling 911, delaying emergency response measures. LVN B failed to perform effective CPR, performing compressions while the resident was on an air mattress in bed. Nursing staff failed to locate necessary supplies in a timely manner to conduct the code. Resident #1 was transported to a local hospital where he was pronounced dead [DATE] at 2:26 a.m. This was determined to be Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at isolated actual harm that is not an IJ because the facility administrative staff had not had time to implement policies and procedures and monitor the effectiveness of training outlined in their Plan of Removal. This failure could affect any of the 32 residents in the facility with physician orders [REDACTED]. The findings include: Review of Resident # 1's Physician order [REDACTED]. His [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS dated [DATE] revealed he had clear speech, was able to understand others and could make himself understood. Review of Resident #1's Annual MDS dated [DATE] revealed he scored a 15 (the highest score possible for cognition) on his BIMS, and he was always incontinent of bowel and bladder. His Active [DIAGNOSES REDACTED]. He used oxygen and received [MEDICAL TREATMENT], and he received insulin injections each of the seven prior days. Review of Resident #1's Care Plan dated [DATE] revealed " ...Full Code..." Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Nurse's Notes dated [DATE] at 2:00 a.m. revealed, "Cked (checked) on res (resident)- res (resident) not breathing- checked for pulse- cold to touch- CPR initiated with another LVN- back board in place- HOB down- Called 911. " In an interview on [DATE] at 5:55 a.m. CNA A stated "a little before 2:00 a.m." LVN A came out of Resident #1's room calling for help, at that time CNA A stated that LVN #A called on her personal cell phone with LVN A's spouse (who was the son of Resident #1 and LVN A's spouse) and was talking to him on the telephone and did not call 911 until after speaking with her spouse. In a written statement by CNA A [DATE] at 4:50 p.m., she wrote at 2:00 a.m. LVN A shouted she needed help because Resident #1 wasn't breathing. LVN B, CNA C and CNA A ran down the hall and LVN A was shaking Resident #1 saying "Pops, wake up ". LVN A then left the room and LVN B told CNA A to get the crash cart. LVN B searched in the crash cart for a mouth piece (for the ambu bag) but couldn't find one. CNA A told CNA B to get the blood pressure cuff and O2 (oxygen) reader since they were not on the crash cart. LVN A was on her cell phone, calling her husband prior to calling 911. LVN B got the CPR board, put it on the floor along with a blanket, and then put it under Resident #1 while in bed which has an air mattress on. CNA C came back with the blood pressure cuff and O2 reader. LVN B yelled at CNA A to check Resident #1's code status. LVN A came in the room and said he was a full code. LVN B put the O2 reader on his finger but nothing was reading so LVN A and LVN B started to perform CPR. They grabbed an ambu bag but there was no mouth piece. LVN A was blowing air without a mouthpiece into Resident #1's mouth while LVN B was doing chest compressions. LVN A left the room to go meet her husband. The paramedics arrived and took over. LVN B was very nervous and she stated that that was her first time performing CPR. In an interview on [DATE] at 6:50 a.m. LVN A stated that the facility did not have the proper equipment to run an effective code, there were no mouthpieces available for resuscitation. In an interview on [DATE] at 4:15 p.m. LVN A stated that when she went to check on Resident #1 just before 2:00 a.m. is when she found that he was not breathing and called LVN B for assistance. She stated that LVN B started chest compressions while LVN A called her spouse. In a written statement by LVN A [DATE] at 4:50 p.m., she revealed at 02:00 a.m. [DATE] she noticed Resident #1 wasn't breathing and called to LVN B for help. LVN A started CPR but stated there was no mouthpiece on the ambu bag. LVN A went to check the chart for code status, which was a Full Code. LVN A called 911 and the family, then returned to room to continue CPR. Ambulance arrived within 5 minutes. When LVN A returned to room, LVN B had the ambu mask. In an interview on [DATE] at 8:20 a.m., CNA C said that when Resident #1 went in to cardiopulmonary arrest on [DATE], LVN A called her husband before calling 911. In an interview on [DATE] at 8:15 a.m., LVN B said that LVN A called out for help from Resident #1's room around 2:00 a.m. [DATE], and told LVN B to get the crash cart. LVN B said she started CPR, but there was no mouthpiece for the ambu bag. LVN B said she put the backboard on Resident #1's air mattress overlay. LVN B said LVN A did not assist with CPR. In a written statement [DATE] at 4:25 p.m., LVN B revealed she was called by LVN A for help. LVN B went to Resident #1's room, who was unresponsive, no pulse, no spontaneous respirations. LVN B told the CNAs to get the crash cart and to check his code status. He was a full code and he was too heavy to take him down to the floor, so they used the back board and started CPR. LVN B sent CNA A to get the other crash cart because she couldn't find the face mask in the crash cart. Before she came back, LVN B found the face mask in a different bag. The first responders arrived, took over resuscitation efforts, and transported Resident #1 to a local hospital. Review of the hospital " Release Of Body " form revealed Resident #1 was pronounced dead [DATE] at 2:26 a.m. In a written statement by CNA B [DATE] at 10:20 a.m., she revealed she worked as an aide on west side with an agency nurse (LVN E). LVN E got a phone call from CNA A asking if we had any CPR mouthpieces. CNA B told LVN E to look on the crash cart. She could not find the correct piece. Both staff walked over to the east side. CNA B waited at the nurses' station while the code was in progress. LVN A's husband walked in right after the paramedics. In an interview with LVN E on [DATE] at 1:45 p.m., she revealed she was an agency nurse who worked at the facility for the first time on the night of [DATE] - [DATE]. LVN E stated she was working on the west side of the building, and received a call from the other nurses ' station asking for a "breather mask." She could not find a mask for an ambu bag on the crash cart. She ran to the east hall, and observed staff performing CPR while the resident was in bed. She told the facility staff that the resident needed to be on the floor. In an interview on [DATE] at 1:30 p.m., the DON said LVN A worked [DATE] 6:00 p.m.-6:00 a.m. [DATE] and [DATE] 6:00 p.m.-6:00 a.m. [DATE]. The DON said LVN A was an experienced nurse who had just started working at the facility [DATE].The DON said LVN A was being trained by LVN B during those two shifts. In an interview on [DATE] at 1:00 p.m., the DON said when Resident #1 was found unresponsive, staff should have responded immediately and started CPR while someone called 911. In an interview on [DATE] at 1:35 p.m., the DON said there was no orientation checklist for LVN A. The DON said she showed the licensed staff the mouthpiece for the ambu bag on [DATE]. She said the night shift was responsible for checking the crash cart each shift. The DON said CPR should be performed on a hard surface. In an interview on [DATE] at 11:17 a.m. with the first responders from the local fire department arrived before the emergency medical services. The first responder stated that there were two staff in the room, one was attempting CPR and the other was attempting to use the ambu bag. He stated that the chest compressions were ineffective because there was no depth to the compressions and the patient was lying on an air mattress instead of a rigid surface and the ambu bag was not placed properly on the patient's face. He stated that the patient's body was cool to touch and had been "down" for longer than a few minutes but not long enough for rigor to have set in. He stated that this had to have been an un-witnessed arrest despite what the nurse stated. In an interview on [DATE] at 9:30 a.m. with the local hospital Emergency Physician stated that for good effective compressions, the patient needed to be on a rigid surface, otherwise while performing chest compression on an air mattress, the chest compressions are ineffective, the entire body would have been moving with each attempted compression. Review of the facility's policy, "Emergency, (Code Blue), Initiation of" dated [DATE] revealed, "...Follow practice guidelines for CPR (cardiopulmonary resuscitation) by initiating "Resuscitation with and without Automatic External Defibrillator (AED), as appropriate, etc. in accordance with patient/resident Advance Directives ...Call 911 for emergency transfer to an acute care center ...Contact patient/resident's physician for further orders ...Contact patient/resident's responsible party ...Continue CPR efforts as appropriate..." "...The depth of compressions should be at least 2 inches - remember: 2 hands, 2 inches. Count aloud as you compress 30 times at the rate of about 3 compressions for every 2 seconds or approximately 100. Put the person on his or her back on a firm surface..." www.cprandfirstaid.com Review of the facility's policy, "Emergency-911" dated [DATE] revealed, "The staff will call 911 for emergency situations ...Qualified staff initiated the appropriate emergency procedures, i.e., oxygen, suction, CPR ...Call 911 when the patient's/resident's condition is life threatening ...Qualified staff attempts to stabilize and monitor the patient/resident until the advance medical team arrives..." This was determined to be Immediate Jeopardy (IJ) on [DATE] at 1:20 p.m. and the DON was informed at that time. The following Plan of Removal for the Immediate Jeopardy was submitted by the facility [DATE]: Issue(s) Identified: 1. Proper equipment on emergency cart 2. Improper code ... Re-education was started immediately with current staff in the facility: 1. Proper equipment on the emergency cart: ? The emergency carts are stocked with the proper equipment. [DATE]. Because we are a medical based institution we are required by law to have an Emergency Cart supplied with the following: (items listed per drawer) ? The emergency carts are being checked each night by the night shift nurses to validate the emergency cart is properly stocked with recommended supplies. [DATE] ? The emergency cart will be re-stocked immediately after each code, by charge nurse that called the code. Nursing management will monitor to validate compliance. ? Licensed staff has been re-educated on emergency cart, that equipment list must match supplies in emergency cart, emergency cart will be restocked by charge nurse that called the code and night shift will check each night. Staff that has not been educated will be required to have the re-education prior to working at the facility. [DATE] ? Licensed staff will be educated on the emergency cart upon hire and annually. ? The Quality Assurance Performance Improvement Committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. 2. Improper code: ? Licensed staff has been re-educated on Code Blue policy and procedure. (attached) [DATE] ? Licensed staff has completed return demonstration on proper CPR (cardiopulmonary resuscitation) [DATE] ? Licensed staff that has not been educated will be required to have the re-education prior to working at the facility. ? Licensed will be educated on the performing proper code with return demonstration upon hire and annually. [DATE] ? The Quality Assurance Performance Improvement Committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. Review of in-service sign-in sheets revealed that the in-services were given to all licensed staff by the facility's staff development coordinator between [DATE] and [DATE]. Review of the crash cart monitoring logs revealed signatures by night shift staff beginning [DATE]. Interviews with licensed staff between [DATE] and [DATE] revealed their ability to state what equipment was on the crash cart, correct procedures for CPR and measures to be taken for signs and symptoms of [DIAGNOSES REDACTED]. On [DATE] at 11:05 a.m., the DON, the Corporate RN, and the Administrator were informed the IJ was lifted. While the IJ was removed, the facility remained out of compliance at a level of isolated actual harm that is not an IJ because the facility administrative staff had not had time to implement policies and procedures and monitor the effectiveness of training outlined in their Plan of Removal. Review of the facility's list dated [DATE] of Residents requesting Full Code status revealed 32 residents.

Based on observations, interviews and record reviews the facility failed to implement policy and procedure that prohibits neglect for one of two sampled residents (Resident #3) reviewed for Foley catheter care. The facility failed to ensure Resident #3 did not suffer from a urinary tract infection that became septic on 3/19/13. - The facility failed to properly assess Resident #3 and when she was sent to the local emergency room via Emergency Medical Services (EMS), she was in septic shock. The facility only notified the physician that she had been vomiting twice the day before, and no one at the facility had assessed her Foley catheter or urine. An Immediate Jeopardy was identified on 3/22/13 at 10:45 a.m. While the Immediate Jeopardy was removed 3/27/13 at 11:00 a.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Seventy-one residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #3 ' s clinical record " Resident Admission Record " documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/29/11 documented she was admitted to the facility with an indwelling Foley catheter with a wound vac to her coccyx. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 6/8/12 documented her Stage IV pressure ulcer to her coccyx had closed. Review of Resident #3 ' s clinical record there was no evidence of documentation of any calls to her physician or attempts to remove the Foley catheter since wound healing. Review of Resident #3 ' s clinical record " Minimum Data Set (MDS) " dated 2/17/13 documented under Speech Clarity Resident #3 was documented as having no speech - absence of spontaneous speech. Under Cognitive Skills for Daily Decision Making, it was documented as severely impaired - never/rarely made decisions. Under Functional Status, Bed Mobility, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Transfer, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Locomotion on Unit, Dressing, Toilet Use, Personal Hygiene, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Bladder and Bowel, Resident #3 was documented as having an indwelling Foley catheter for urine elimination and Ostomy for bowel movements. Review of Resident #3 ' s clinical record " Care Plan " dated 2/28/13 documented under Problem documented " .....I have a potential for compromised psychosocial well-being due to being a bed bound resident in the facility I reside in .... " Problem documented " ....Due to my health status I stay in my room. I like to listen to music or the TV. I need assistance turning the TV on, or on the radio, occasionally I attend to special events, and also I enjoy my family visits ..... " Problem documented " .....I am bedfast and my cognitive status/decision making skills are impaired ....I require extensive to total assistance with ADL ' s (Activities of Daily Living) .....Under Goal documented " ....I will have my needs anticipated and met by staff for 90 days .... " Review of Resident #3 ' s clinical record " Physician ' s Progress Notes " dated 3/19/13 untimed, documented " .....staff reported patient vomited twice over night ....up in wheelchair ....alert, no fever, no acute distress, will watch ....[MEDICATION NAME] (anti-emetic used for nausea/vomiting) prn (as needed) ... .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/18/13 at 2310 (11:10 p.m.) documented by LVN #7 " .....resident vomited times one, [MEDICATION NAME] as needed 25 mg po (by mouth) given ....HOB (head of bed) elevated ....physician notified ..... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0300 (3:00 a.m.) documented by LVN #7 " ... ...feeding resident, vomited again and physician ' s office notified .....order hold feeding and give [MEDICATION NAME] 25 mg po (per oral or by mouth) .... Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0800 (8:00 a.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....respirations regular and non-labored, lung sounds clear to auscultation in front and back .....abdomen soft and non-distended ... ...bowel sounds in four quadrants ... ...[DEVICE] (an artificial opening on the abdomen that enters the stomach for the purpose of liquid feeding formula) patent and intact .....no signs/symptoms of aspiration noted .....Placement checked, no residual noted ....breakfast feedings held due to patient ate 50% of meal .....family called and notified about resident vomiting last night .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 10:00 a.m. documented by LVN #2 " ... ...resident resting in bed with eyes open, respirations regular and non-labored, lung sounds clear to auscultation in front and back .....[DEVICE] patent and intact ....Foley catheter patent and draining clear yellow urine ....[MEDICAL CONDITION] patent with soft stool in bag .....HOB elevated ...no distress noted at this time ... ... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 12:35 p.m. documented by LVN #2 " ... ...physician here to assess resident .....see progress notes .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 1340 (1:40 p.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....HOB elevated ....Vital Signs (VS) blood pressure 118/54, heart rate 135, respirations 36, temperature 96.5, oxygen saturation 96%...accu-check (a finger stick used to collect blood to measure blood glucose (sugar) levels) 235 .....responding slightly to verbal stimuli ...diaphoretic and [MEDICAL CONDITION] .....lung sounds clear to auscultation, no nausea/vomiting noted ....Foley catheter patent draining clear yellow urine, [DEVICE] patent ....[MEDICAL CONDITION] patent with soft stool present .....send resident to emergency department for evaluation and treatment .....physician and family notified ..... " Record review of the local EMS (emergency medical services) " Run Sheet " dated 3/19/13 beginning at 1418 (2:18 p.m.) and ending at the local emergency department at 1432 (2:42 p.m.), when arrived at the local emergency department, documented " ....staff states patient vomited twice previously .....requesting transport for possible aspiration - patient has history of severe dementia .....tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate) [MEDICAL CONDITION] (low blood pressure) and diaphoresis (sweating) .....patient transferred to EMS cot via three person lift ....IV attempt twice was unsuccessful ....impression - septic shock ..... " Review of the EMS " Run Sheet " dated 3/19/13 at 1418 (2:18 p.m.) the first set of vital signs were documented the blood pressure as 89/53, pulse 134, respirations 20. Observation on 3/21/13 at 9:00 a.m. at the local hospital Intensive Care Unit revealed Resident #3 had a large unstageable pressure sore on her right heel. In an interview on 3/22/13 at 1:10 p.m. the Emergency Department Registered Nurse that received Resident #3 into the emergency department stated that when she received Resident #3 from the emergency medical services, Resident #3 was not alert, her rectal temperature was elevated and her Foley catheter was draining thick gray pus. She stated that Resident #3 was in a very bad state, diaphoretic (soaked in sweat) and had a general bad odor about her. She stated that Resident #3 was very dirty when she arrived to the emergency room . In an interview on 3/21/13 at 8:15 a.m. Intensive Care Unit (ICU) nurse (ICU nurse #1) that had care for Resident #3 when she was first admitted to the ICU stated that when she received Resident #3 from the emergency room , that Resident #3 was filthy and her Foley catheter had sludge in the tubing clotting off the urine from going into the drainage collection bag. She described the urine as cloudy, nasty green/gray in color and when she removed the Foley that she came to the hospital with from the facility, the tubing was stained and dirty. ICU nurse #1 described that when she removed the old Foley, there were three ICU nurses in the room assisting and two of the ICU nurse ' s had to leave the room vomiting from the overwhelming odor of the urine that saturated the bedding of Resident #3. She stated that after placing a new Foley catheter in Resident #3 and after Resident #3 urinated and soaked the entire bed, Resident #3 voided almost 500 cc (cubic centimeters) of cloudy, dark, thick urine. She stated that Resident #3 had dried stool on her buttocks and abdomen. She stated that she had given Resident #3 two head to toe bed baths during her shift and Resident #3 still was not clean when she turned over care to the oncoming nurse. In an interview on 3/25/13 at 10:50 a.m. Intensive Care Unit (ICU) nurse #2 that took over care of Resident #3 stated that she also gave Resident #3 two complete head to toe bed baths and finally got her cleaned up. She stated that she had called the facility asking when Resident #3 ' s Foley catheter was last changed and the DON told her that it was 2/25/13. The ICU nurse stated that she also informed the DON at the facility that when Resident #3 arrived, she was filthy and her urine was thick, gray sludge and wanted to know how Resident #3 had been cared for. In an interview on 3/21/13 at 8:30 a.m. Resident #3 ' s four daughters were present and stated that the first time they heard of their mother being admitted to the intensive care unit (ICU) was 3/19/13 at night (they were not sure at what time, but it was late evening) when the ICU nurse called them to come see their mother, that she was in critical condition and was not expected to survive. The daughters stated that they had called the facility and spoken with the Administrator and DON about their care concerns for Resident #3. The daughters stated that they had placed a sign above their mother ' s bed with times to be up in the Geri-chair and when to be placed back in bed. They stated that often times their mother would be in the same clothes for several days at a time, that her eyes were frequently matted and the CNA ' s would often leave her dirty frequently. They also stated that there was one CNA that manually picked their mother up from the Geri-chair by herself and placed their mother onto the bed. They stated that their mother was to be transferred by the Hoyer lift only and with two person assist. Review of the local hospital ' s medical records for Resident #3 documented by the first ICU nurse on 3/19/13 at 2100 (9:00 p.m.) documented " ... ....Patient Diagnosis: [REDACTED]..catheter removed and replaced on admission ....Patient voided a large amount of urine incontinently immediately after catheter was removed ... ...urine foul smelling, dark, cloudy and concentrated ....New Foley catheter inserted ..... " Review of the local hospitals medical records for Resident #3 documented by the first ICU nurse on 3/21/13 at 8:00 a.m. " ... ....I received the patient 3/19/13 and her Foley catheter appeared extremely dirty ....urine was very cloudy, a grey-amber color and had an overwhelmingly foul odor ....There was minimal urine output in the bag and urine was stationary in the tubing .....Upon taking out the Foley catheter, patient voided a great amount of urine described above ...after inserting the new catheter, patient immediately had out 450cc of urine described above ....patient was very unclean .... " Review of the hospital ' s " Patient Results " dated 3/19/13 at 1531 (3:51 p.m.) documented the culture and sensitivity (C&S) results as Proteus Mirabilis and Escherichia Coli (both are bacteria commonly found in feces {stool}). Observation on 3/21/13 at 7:50 a.m. at the local hospital Intensive Care Unit (ICU) revealed that Resident #3 had an Indwelling Foley Catheter draining thick, dark amber urine. The ICU nurse caring for Resident #3 stated that the urine looked " so much better " than when she first received her. At this time, Resident #3 was being transferred to another unit at the hospital. Observation on 3/21/13 at 8:45 a.m. at the local hospital in a regular hospital room revealed Resident #3 had an unstageable pressure ulcer located on her right heel that the facility had no evidence of documentation. Also she had two stage II pressure ulcers on the lateral aspect of her right foot. In an interview on 3/22/13 at 10:10 a.m. LVN #3 stated that she had changed the indwelling urinary catheter on Resident #3 on 2/25/13 when she was still working nights. She stated that the nurse working on the west side stated she did not know how to change an indwelling urinary catheter on a resident that was contracted. LVN #3 stated that the old urinary catheter had sediment in the tubing clogging off the flow of urine into the collection bag. LVN #3 stated that when she placed the new indwelling urinary catheter it immediately began draining without any difficulties. LVN #3 stated that she did not detect any odor about Resident #3 or the urine when she changed the catheter on 2/25/13. LVN #3 stated that she did not notify the physician due to the amount of sediment in the catheter tubing. LVN #3 stated that in her professional opinion indwelling urinary catheters should be changed at least once a month or more often if needed. LVN #3 stated in her professional opinion that it would take a very long time for urine to go from clear yellow to thick gray sludge, she was unable to give an estimate on how long it would take. In an interview on 3/21/13 at 11:30 a.m. ADON #2 accompanied this investigator to see the residents that was on the CMS Form 672 dated 3/21/13 that documented the facility having four residents in the facility as having a Foley catheter. Observation at this time revealed only one other resident (Resident #1) as having an indwelling urinary catheter. Resident #12 had not had a Foley catheter " ....for the past three weeks, she pulled her catheter out and hospice said to leave it out .... " There was no evidence of documentation of a physician order [REDACTED]. Resident #6 had not had a catheter since before 10/5/13 when hospice performed an in and out catherization to obtain urine for a urinalysis and culture and sensitivity for a suspected urinary tract infection. ADON #2 stated sarcastically " ....evidently I really know my residents ..... " There was no evidence of documentation of an order to take or leave the catheter out. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that in her professional opinion Foley catheters should be changed monthly. She also stated that some nurse aides measure the urine and document it and some aides only document urine amounts as small, medium or large. In an interview on 3/22/13 at 10:45 a.m. ADON #2 stated that the assessment completed on Resident #3 was a wrong assessment because the nurse did not do a head to toe assessment and the documentation on the assessment documented Resident #3 ' s urine as clear yellow urine. She stated that LVN#2 did not do a complete assessment of Resident #3 due to the fact that LVN #2 had not documented in Resident #3 ' s clinical record regarding the color and clarity of Resident #3 ' s urine until 3/19/13. In an interview on 3/25/13 at 11:39 a.m. CNA #3 stated that she had emptied Resident #3 ' s drainage bag on 3/19/13 before she went off shift at 6:00 a.m. and at that time the urine in the drainage bag was yellow and had bacteria in it. She explained that by having bacteria in the urine she meant that the urine was white and cloudy and to her it looked like this white cloudy stuff was clogging the tubing. She stated that she reported it to the day nurse who was LVN #2. In an interview on 3/22/13 at 11:00 a.m. LVN #2 stated that Resident #3 had vomited twice the night before (3/18/13) she was sent to the hospital. He stated that Resident #3 ate breakfast in bed but did not eat any lunch. The physician saw her and said she was fine. A few hours later (approximately 55 minutes) she started sweating a lot and her pulse rate got fast. LVN #2 stated that Resident #3 was mumbling and not doing the stuff she normally does. After lunch she was not responding, was breathing fast and was sweaty. LVN #2 described Resident #3 ' s urine as being yellow, clear and draining, but he was unable to state how much he observed in the bag at the time of the transfer. In an interview on 3/22/13 at 11:10 a.m. LVN #1 stated that if a resident with a urinary catheter had appeared to have a urinary tract infection it would be best to go ahead and change the catheter, even if waiting on a urinalysis. In an interview on 3/22/13 at 11:15 a.m. LVN #1 stated there were no open areas on Resident #3 ' s feet and that he had assess her skin the morning prior to her being sent to the emergency department and that he did not look at her urine. In an interview on 3/22/13 at 12:20 p.m. the Medical Director for the facility stated that he was unaware that the facility had changed their policy of changing indwelling urinary catheters monthly to as needed. He stated that in his professional medical opinion, urinary catheters needed to be changed at least once a month or sooner if needed. He stated that " .....I just don ' t know what to do with that facility .... " In an interview on 3/22/13 at 3:05 p.m. the DON stated that she tracks bowel movements, oral and [DEVICE] administered intakes. She stated that she does not see anything on outputs (such as urine). She stated that the system goes down every day at 2:00 a.m. and 2:00 p.m. but it does not stay down for very long (she was unable to give an estimated amount of time the system would be down). She stated that she had been training staff on fluid intake. In an interview on 3/22/13 at 3:15 p.m. CNA #5 stated that when she worked with Resident #3 on 3/18/13 the urine was dark yellow and she did not think anything of it because since her employment began in August 2012, Resident #3 ' s urine had always been dark yellow with " stuff " in the tubing. CNA #5 stated that the reason she did not tell any of the charge nurses about the color and clarity of Resident #3 ' s urine was because the urine hadn ' t changed since she had begun working in August, 2012. In an interview on 3/22/13 at 3:25 p.m. CNA #6 stated that she would go and ask the nurse how to input color, consistency and amount of urine into the kiosk. She stated that it was very important to keep the catheter clean and to be very careful while completing peri-care because it they didn ' t want to give the residents who have indwelling urinary catheters an infection. In an interview on 3/24/13 at 8:20 a.m. RN #1 stated that she worked weekends, but had been off and had not worked with Resident #3 for over a month. During the interview she said that in her professional opinion indwelling urinary catheters should be change done a month or sooner if needed. RN #1 was no aware of any facility criteria for changing out urinary catheters. In an interview on 3/25/13 at 10:20 a.m. ADON #2 stated that the nurse who had been doing infection control left in January 2013 and that she (ADON #2) had been trying " to keep up with it " . She said she was not aware that Proteus Mirabalis was a fecal bacterium. She was not aware of any recent in-services on incontinent care. In an interview on 3/25/13 at 1:30 p.m. CNA #2 stated that the last time she had taken care (which was documented on the kiosk as 3/10/13) of Resident #3 she reported to the nurse that the urine was a dark brown color and that she did inform the charge nurse, but was unable to state which nurse she had reported this to. CNA #2 stated that it was the day charge nurse for the west side. In an interview on 3/27/13 at 9:30 a.m. ADON #2 stated that she had no instruction on how to fill out the Infection Control Log. The Administrator, DON, RNC #1 was informed 3/22/13 at 10:45 a.m. that Immediate Jeopardy was declared. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "3/22/13 revised 3/27/13" accepted at 11:00 a.m. documented ".....The Immediate Jeopardy was declared at 10:45 a.m. on 3/22/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education being presented to the facility staff nurses by the Director of Nursing/Unit Managers. - Incontinent Care - Foley Catheter Care - Foley Catheter Assessments and Documentation of color/clarity/characteristics by licensed nurse Re-education was started immediately with current staff in the facility: (copies of education provided is attached). In-service has been provided for licensed nurses for re-education regarding importance of Foley catheter care, documenting after Certified Nursing assistants provides Foley catheter care, and nurse assessment of patency of catheter, color and clarity of urine every shift. As of 3/26/13 at 11:30 a.m. all certified nursing assistants have been re-educated on incontinent care, Foley catheter care and successfully performed incontinent care observed by the Director of Nursing and/or Assistant Directors of Nursing using the skills checklist for incontinent care (sample attached). The exception is three certified nursing assistants who are prn (as needed) and are not scheduled. These three identified certified nursing assistants will not be allowed to work until they have been re-educated and successfully completed incontinent care using the skills checklist for incontinent care. All licensed charge nurses have been re-educated on Foley catheters and incontinent care including documentation. The exception is one PRN (as needed) licensed nurses who is not scheduled to work and will not be allowed to work until the re-education is completed. System Changes: There are no residents with Foley catheters in the facility as of 3/25/13 at 7:00 p.m. Future orders for Foley catheters will read: Change indwelling Foley catheters as needed prn dysfunction. Certified Nursing Assistants are required to not only document urine output of resident ' s with Foley catheters in the Kiosk with the amount of urine in cc ' s (cubic centimeters) on their shift, but also report to the nurse if they notice any changes in urine color and if there is absence of urine output at any time during their shift. At that time, the charge nurse will assess the resident for change of condition, report to family and physician and carry out any new orders received. Director of Nursing/designee reviews a report from the Kiosk Monday through Friday and the weekend RN will run report to review output of residents with Foley catheter to review urine output documentation. Any missing documentation on urine output of resident ' s with Foley catheters has been addressed and a late entry made in the chart to reflect urine output for any missing documentation. A line has been added on the Nurses ' Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. As of 3/26/13 at 11:30 a.m. all current incontinent residents have been assessed for any signs and symptoms of urinary tract infection. One resident on the east side had no change in urine odor, vital signs stable, but complained of lower back pain. Physician notified of complaint and order received for lab urinalysis and culture and sensitivity. Family has been notified of complaint and new order. One resident on the west side had vital signs within normal limits, no complaints, but did have a change in urine odor. Physician has been notified of this change. Resident is aware of the call to the physician. These assessments and findings have been documented in the resident ' s medical record. Resident on east side with Foley catheter was assessed and a physician order [REDACTED]. Family notified. Catheter has been discontinued and resident is voiding without difficulty. Post void residual of 30 cc (cubic centimeters) was obtained via straight catheter per physician's order [REDACTED]. Certified nursing assistants are toileting the resident and she is voiding on the toilet. Certified nursing assistants are reporting results to nurse. This resident will be reassessed using the Bladder Assessment to determine continence and care plans will be developed based upon results. The Medical Director has been made aware of the alleged deficient practice and plans in place to correct. The Performance Improvement Committee will review the above actions taken by the facility to correct the alleged deficient practice. The Director of Nursing will report progress to the Performance Improvement Committee monthly for three months and then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions. On 3/27/13 at 11:00 a.m. the Immediate Jeopardy was lowered to a scope and severity of actual harm that is not Immediate Jeopardy level at a pattern. CMS Form 672 dated 3/21/13 documented four residents having an indwelling urinary catheter, upon observation, there was only one resident with an indwelling urinary catheter besides Resident #3.

Based on observations, interviews and record reviews the facility failed to implement written policy and procedure that prohibits neglect for one of two sampled residents (Resident #3) reviewed for Foley catheter care. The facility failed to ensure Resident #3 did not suffer from a urinary tract infection that became septic on 3/19/13. - The facility failed to properly assess Resident #3 and when she was sent to the local emergency room via Emergency Medical Services (EMS), she was in septic shock. The facility only notified the physician that she had been vomiting twice the day before, and no one at the facility had assessed her Foley catheter or urine. Review of the facility's Policy and Procedure "Detecting and Reporting Abuse" undated documented "......Neglect is defined as the refusal or failure to provide a person with the necessities of life including, but not limited to, food, shelter, clothing and the provision of medical care........" An Immediate Jeopardy was identified on 3/22/13 at 10:45 a.m. with the Administrator, DON and RNC #1 present. While the Immediate Jeopardy was removed 3/27/13 at 11:00 a.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Seventy-one residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #3 ' s clinical record " Resident Admission Record " documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/29/11 documented she was admitted to the facility with an indwelling Foley catheter with a wound vac to her coccyx. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 6/8/12 documented her Stage IV pressure ulcer to her coccyx had closed. Review of Resident #3 ' s clinical record there was no evidence of documentation of any calls to her physician or attempts to remove the Foley catheter since wound healing. Review of Resident #3 ' s clinical record " Minimum Data Set (MDS) " dated 2/17/13 documented under Speech Clarity Resident #3 was documented as having no speech - absence of spontaneous speech. Under Cognitive Skills for Daily Decision Making, it was documented as severely impaired - never/rarely made decisions. Under Functional Status, Bed Mobility, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Transfer, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Locomotion on Unit, Dressing, Toilet Use, Personal Hygiene, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Bladder and Bowel, Resident #3 was documented as having an indwelling Foley catheter for urine elimination and Ostomy for bowel movements. Review of Resident #3 ' s clinical record " Care Plan " dated 2/28/13 documented under Problem documented " .....I have a potential for compromised psychosocial well-being due to being a bed bound resident in the facility I reside in .... " Problem documented " ....Due to my health status I stay in my room. I like to listen to music or the TV. I need assistance turning the TV on, or on the radio, occasionally I attend to special events, and also I enjoy my family visits ..... " Problem documented " .....I am bedfast and my cognitive status/decision making skills are impaired ....I require extensive to total assistance with ADL ' s (Activities of Daily Living) .....Under Goal documented " ....I will have my needs anticipated and met by staff for 90 days .... " Review of Resident #3 ' s clinical record " Physician ' s Progress Notes " dated 3/19/13 untimed, documented " .....staff reported patient vomited twice over night ....up in wheelchair ....alert, no fever, no acute distress, will watch ....[MEDICATION NAME] (anti-emetic used for nausea/vomiting) prn (as needed) ... .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/18/13 at 2310 (11:10 p.m.) documented by LVN #7 " .....resident vomited times one, [MEDICATION NAME] as needed 25 mg po (by mouth) given ....HOB (head of bed) elevated ....physician notified ..... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0300 (3:00 a.m.) documented by LVN #7 " ... ...feeding resident, vomited again and physician ' s office notified .....order hold feeding and give [MEDICATION NAME] 25 mg po (per oral or by mouth) .... Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0800 (8:00 a.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....respirations regular and non-labored, lung sounds clear to auscultation in front and back .....abdomen soft and non-distended ... ...bowel sounds in four quadrants ... ...[DEVICE] (an artificial opening on the abdomen that enters the stomach for the purpose of liquid feeding formula) patent and intact .....no signs/symptoms of aspiration noted .....Placement checked, no residual noted ....breakfast feedings held due to patient ate 50% of meal .....family called and notified about resident vomiting last night .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 10:00 a.m. documented by LVN #2 " ... ...resident resting in bed with eyes open, respirations regular and non-labored, lung sounds clear to auscultation in front and back .....[DEVICE] patent and intact ....Foley catheter patent and draining clear yellow urine ....[MEDICAL CONDITION] patent with soft stool in bag .....HOB elevated ...no distress noted at this time ... ... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 12:35 p.m. documented by LVN #2 " ... ...physician here to assess resident .....see progress notes .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 1340 (1:40 p.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....HOB elevated ....Vital Signs (VS) blood pressure 118/54, heart rate 135, respirations 36, temperature 96.5, oxygen saturation 96%...accu-check (a finger stick used to collect blood to measure blood glucose (sugar) levels) 235 .....responding slightly to verbal stimuli ...diaphoretic and [MEDICAL CONDITION] .....lung sounds clear to auscultation, no nausea/vomiting noted ....Foley catheter patent draining clear yellow urine, [DEVICE] patent ....[MEDICAL CONDITION] patent with soft stool present .....send resident to emergency department for evaluation and treatment .....physician and family notified ..... " Record review of the local EMS (emergency medical services) " Run Sheet " dated 3/19/13 beginning at 1418 (2:18 p.m.) and ending at the local emergency department at 1432 (2:42 p.m.), when arrived at the local emergency department, documented " ....staff states patient vomited twice previously .....requesting transport for possible aspiration - patient has history of severe dementia .....tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate) [MEDICAL CONDITION] (low blood pressure) and diaphoresis (sweating) .....patient transferred to EMS cot via three person lift ....IV attempt twice was unsuccessful ....impression - septic shock ..... " Review of the EMS " Run Sheet " dated 3/19/13 at 1418 (2:18 p.m.) the first set of vital signs were documented the blood pressure as 89/53, pulse 134, respirations 20. Observation on 3/21/13 at 9:00 a.m. at the local hospital Intensive Care Unit revealed Resident #3 had a large unstageable pressure sore on her right heel. In an interview on 3/22/13 at 1:10 p.m. the Emergency Department Registered Nurse that received Resident #3 into the emergency department stated that when she received Resident #3 from the emergency medical services, Resident #3 was not alert, her rectal temperature was elevated and her Foley catheter was draining thick gray pus. She stated that Resident #3 was in a very bad state, diaphoretic (soaked in sweat) and had a general bad odor about her. She stated that Resident #3 was very dirty when she arrived to the emergency room . In an interview on 3/21/13 at 8:15 a.m. Intensive Care Unit (ICU) nurse (ICU nurse #1) that had care for Resident #3 when she was first admitted to the ICU stated that when she received Resident #3 from the emergency room , that Resident #3 was filthy and her Foley catheter had sludge in the tubing clotting off the urine from going into the drainage collection bag. She described the urine as cloudy, nasty green/gray in color and when she removed the Foley that she came to the hospital with from the facility, the tubing was stained and dirty. ICU nurse #1 described that when she removed the old Foley, there were three ICU nurses in the room assisting and two of the ICU nurse ' s had to leave the room vomiting from the overwhelming odor of the urine that saturated the bedding of Resident #3. She stated that after placing a new Foley catheter in Resident #3 and after Resident #3 urinated and soaked the entire bed, Resident #3 voided almost 500 cc (cubic centimeters) of cloudy, dark, thick urine. She stated that Resident #3 had dried stool on her buttocks and abdomen. She stated that she had given Resident #3 two head to toe bed baths during her shift and Resident #3 still was not clean when she turned over care to the oncoming nurse. In an interview on 3/25/13 at 10:50 a.m. Intensive Care Unit (ICU) nurse #2 that took over care of Resident #3 stated that she also gave Resident #3 two complete head to toe bed baths and finally got her cleaned up. She stated that she had called the facility asking when Resident #3 ' s Foley catheter was last changed and the DON told her that it was 2/25/13. The ICU nurse stated that she also informed the DON at the facility that when Resident #3 arrived, she was filthy and her urine was thick, gray sludge and wanted to know how Resident #3 had been cared for. In an interview on 3/21/13 at 8:30 a.m. Resident #3 ' s four daughters were present and stated that the first time they heard of their mother being admitted to the intensive care unit (ICU) was 3/19/13 at night (they were not sure at what time, but it was late evening) when the ICU nurse called them to come see their mother, that she was in critical condition and was not expected to survive. The daughters stated that they had called the facility and spoken with the Administrator and DON about their care concerns for Resident #3. The daughters stated that they had placed a sign above their mother ' s bed with times to be up in the Geri-chair and when to be placed back in bed. They stated that often times their mother would be in the same clothes for several days at a time, that her eyes were frequently matted and the CNA ' s would often leave her dirty frequently. They also stated that there was one CNA that manually picked their mother up from the Geri-chair by herself and placed their mother onto the bed. They stated that their mother was to be transferred by the Hoyer lift only and with two person assist. Review of the local hospital ' s medical records for Resident #3 documented by the first ICU nurse on 3/19/13 at 2100 (9:00 p.m.) documented " ... ....Patient Diagnosis: [REDACTED]..catheter removed and replaced on admission ....Patient voided a large amount of urine incontinently immediately after catheter was removed ... ...urine foul smelling, dark, cloudy and concentrated ....New Foley catheter inserted ..... " Review of the local hospitals medical records for Resident #3 documented by the first ICU nurse on 3/21/13 at 8:00 a.m. " ... ....I received the patient 3/19/13 and her Foley catheter appeared extremely dirty ....urine was very cloudy, a grey-amber color and had an overwhelmingly foul odor ....There was minimal urine output in the bag and urine was stationary in the tubing .....Upon taking out the Foley catheter, patient voided a great amount of urine described above ...after inserting the new catheter, patient immediately had out 450cc of urine described above ....patient was very unclean .... " Review of the hospital ' s " Patient Results " dated 3/19/13 at 1531 (3:51 p.m.) documented the culture and sensitivity (C&S) results as Proteus Mirabilis and Escherichia Coli (both are bacteria commonly found in feces {stool}). Observation on 3/21/13 at 7:50 a.m. at the local hospital Intensive Care Unit (ICU) revealed that Resident #3 had an Indwelling Foley Catheter draining thick, dark amber urine. The ICU nurse caring for Resident #3 stated that the urine looked " so much better " than when she first received her. At this time, Resident #3 was being transferred to another unit at the hospital. Observation on 3/21/13 at 8:45 a.m. at the local hospital in a regular hospital room revealed Resident #3 had an unstageable pressure ulcer located on her right heel that the facility had no evidence of documentation. Also she had two stage II pressure ulcers on the lateral aspect of her right foot. In an interview on 3/22/13 at 10:10 a.m. LVN #3 stated that she had changed the indwelling urinary catheter on Resident #3 on 2/25/13 when she was still working nights. She stated that the nurse working on the west side stated she did not know how to change an indwelling urinary catheter on a resident that was contracted. LVN #3 stated that the old urinary catheter had sediment in the tubing clogging off the flow of urine into the collection bag. LVN #3 stated that when she placed the new indwelling urinary catheter it immediately began draining without any difficulties. LVN #3 stated that she did not detect any odor about Resident #3 or the urine when she changed the catheter on 2/25/13. LVN #3 stated that she did not notify the physician due to the amount of sediment in the catheter tubing. LVN #3 stated that in her professional opinion indwelling urinary catheters should be changed at least once a month or more often if needed. LVN #3 stated in her professional opinion that it would take a very long time for urine to go from clear yellow to thick gray sludge, she was unable to give an estimate on how long it would take. In an interview on 3/21/13 at 11:30 a.m. ADON #2 accompanied this investigator to see the residents that was on the CMS Form 672 dated 3/21/13 that documented the facility having four residents in the facility as having a Foley catheter. Observation at this time revealed only one other resident (Resident #1) as having an indwelling urinary catheter. Resident #12 had not had a Foley catheter " ....for the past three weeks, she pulled her catheter out and hospice said to leave it out .... " There was no evidence of documentation of a physician order [REDACTED]. Resident #6 had not had a catheter since before 10/5/13 when hospice performed an in and out catherization to obtain urine for a urinalysis and culture and sensitivity for a suspected urinary tract infection. ADON #2 stated sarcastically " ....evidently I really know my residents ..... " There was no evidence of documentation of an order to take or leave the catheter out. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that in her professional opinion Foley catheters should be changed monthly. She also stated that some nurse aides measure the urine and document it and some aides only document urine amounts as small, medium or large. In an interview on 3/22/13 at 10:45 a.m. ADON #2 stated that the assessment completed on Resident #3 was a wrong assessment because the nurse did not do a head to toe assessment and the documentation on the assessment documented Resident #3 ' s urine as clear yellow urine. She stated that LVN#2 did not do a complete assessment of Resident #3 due to the fact that LVN #2 had not documented in Resident #3 ' s clinical record regarding the color and clarity of Resident #3 ' s urine until 3/19/13. In an interview on 3/25/13 at 11:39 a.m. CNA #3 stated that she had emptied Resident #3 ' s drainage bag on 3/19/13 before she went off shift at 6:00 a.m. and at that time the urine in the drainage bag was yellow and had bacteria in it. She explained that by having bacteria in the urine she meant that the urine was white and cloudy and to her it looked like this white cloudy stuff was clogging the tubing. She stated that she reported it to the day nurse who was LVN #2. In an interview on 3/22/13 at 11:00 a.m. LVN #2 stated that Resident #3 had vomited twice the night before (3/18/13) she was sent to the hospital. He stated that Resident #3 ate breakfast in bed but did not eat any lunch. The physician saw her and said she was fine. A few hours later (approximately 55 minutes) she started sweating a lot and her pulse rate got fast. LVN #2 stated that Resident #3 was mumbling and not doing the stuff she normally does. After lunch she was not responding, was breathing fast and was sweaty. LVN #2 described Resident #3 ' s urine as being yellow, clear and draining, but he was unable to state how much he observed in the bag at the time of the transfer. In an interview on 3/22/13 at 11:10 a.m. LVN #1 stated that if a resident with a urinary catheter had appeared to have a urinary tract infection it would be best to go ahead and change the catheter, even if waiting on a urinalysis. In an interview on 3/22/13 at 11:15 a.m. LVN #1 stated there were no open areas on Resident #3 ' s feet and that he had assess her skin the morning prior to her being sent to the emergency department and that he did not look at her urine. In an interview on 3/22/13 at 12:20 p.m. the Medical Director for the facility stated that he was unaware that the facility had changed their policy of changing indwelling urinary catheters monthly to as needed. He stated that in his professional medical opinion, urinary catheters needed to be changed at least once a month or sooner if needed. He stated that " .....I just don ' t know what to do with that facility .... " In an interview on 3/22/13 at 3:05 p.m. the DON stated that she tracks bowel movements, oral and [DEVICE] administered intakes. She stated that she does not see anything on outputs (such as urine). She stated that the system goes down every day at 2:00 a.m. and 2:00 p.m. but it does not stay down for very long (she was unable to give an estimated amount of time the system would be down). She stated that she had been training staff on fluid intake. In an interview on 3/22/13 at 3:15 p.m. CNA #5 stated that when she worked with Resident #3 on 3/18/13 the urine was dark yellow and she did not think anything of it because since her employment began in August 2012, Resident #3 ' s urine had always been dark yellow with " stuff " in the tubing. CNA #5 stated that the reason she did not tell any of the charge nurses about the color and clarity of Resident #3 ' s urine was because the urine hadn ' t changed since she had begun working in August, 2012. In an interview on 3/22/13 at 3:25 p.m. CNA #6 stated that she would go and ask the nurse how to input color, consistency and amount of urine into the kiosk. She stated that it was very important to keep the catheter clean and to be very careful while completing peri-care because it they didn ' t want to give the residents who have indwelling urinary catheters an infection. In an interview on 3/24/13 at 8:20 a.m. RN #1 stated that she worked weekends, but had been off and had not worked with Resident #3 for over a month. During the interview she said that in her professional opinion indwelling urinary catheters should be change done a month or sooner if needed. RN #1 was no aware of any facility criteria for changing out urinary catheters. In an interview on 3/25/13 at 10:20 a.m. ADON #2 stated that the nurse who had been doing infection control left in January 2013 and that she (ADON #2) had been trying " to keep up with it " . She said she was not aware that Proteus Mirabalis was a fecal bacterium. She was not aware of any recent in-services on incontinent care. In an interview on 3/25/13 at 1:30 p.m. CNA #2 stated that the last time she had taken care (which was documented on the kiosk as 3/10/13) of Resident #3 she reported to the nurse that the urine was a dark brown color and that she did inform the charge nurse, but was unable to state which nurse she had reported this to. CNA #2 stated that it was the day charge nurse for the west side. Review of the facility ' s Infection Reports revealed two forms being used. One contained the questions " Health Care Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " which had yes or no answers. The second Infection Report Form documented " ....Facility Acquired Infection developed after admission? " and " Community Acquired Evidence of Infection at time of admission? " Both with yes or no answers. Seventeen Infection Reports of residents with UTI ' s were reviewed for whether they were marked to indicate if the UTI was an HAI or CAI. Nine of the reports had both questions marked " No " , seven had neither question answered, and one had HAI question left blank and answered " No " on the CAI question. In an interview on 3/26/13 at 10:50 a.m. with the DON, ADON #2 and RNC #1, RNC #1 stated that there were criteria for determining if a resident infection was a Healthcare Associated Infection (HAI) and ADON #2 pointed to the criteria listed on the HAI form. In an interview on 3/26/13 at 3:50 p.m. and 4:30 p.m. RNC #2 stated that on the Infection Report form the questions " Healthcare Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " should be answered either yes or no. If the HAI question is answered " yes " , then the Healthcare Associated Infection Surveillance Report Form should be filled out. RNC #2 stated that the Infection Control Policy criteria was to determine if there was an infection and the HAI Surveillance Report Form criteria was to help determine if the infection was chronic or acute. In an interview on 3/27/13 at 9:30 a.m. ADON #2 stated that she had no instruction on how to fill out the Infection Control Log. The Administrator, DON, RNC #1 were informed 3/22/13 at 10:45 a.m. that Immediate Jeopardy was declared. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "3/22/13 revised 3/27/13" accepted at 11:00 a.m. documented ".....The Immediate Jeopardy was declared at 10:45 a.m. on 3/22/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education being presented to the facility staff nurses by the Director of Nursing/Unit Managers. - Incontinent Care - Foley Catheter Care - Foley Catheter Assessments and Documentation of color/clarity/characteristics by licensed nurse Re-education was started immediately with current staff in the facility: (copies of education provided is attached). In-service has been provided for licensed nurses for re-education regarding importance of Foley catheter care, documenting after Certified Nursing assistants provides Foley catheter care, and nurse assessment of patency of catheter, color and clarity of urine every shift. As of 3/26/13 at 11:30 a.m. all certified nursing assistants have been re-educated on incontinent care, Foley catheter care and successfully performed incontinent care observed by the Director of Nursing and/or Assistant Directors of Nursing using the skills checklist for incontinent care (sample attached). The exception is three certified nursing assistants who are prn (as needed) and are not scheduled. These three identified certified nursing assistants will not be allowed to work until they have been re-educated and successfully completed incontinent care using the skills checklist for incontinent care. All licensed charge nurses have been re-educated on Foley catheters and incontinent care including documentation. The exception is one PRN (as needed) licensed nurses who is not scheduled to work and will not be allowed to work until the re-education is completed. System Changes: There are no residents with Foley catheters in the facility as of 3/25/13 at 7:00 p.m. Future orders for Foley catheters will read: Change indwelling Foley catheters as needed prn dysfunction. Certified Nursing Assistants are required to not only document urine output of resident ' s with Foley catheters in the Kiosk with the amount of urine in cc ' s (cubic centimeters) on their shift, but also report to the nurse if they notice any changes in urine color and if there is absence of urine output at any time during their shift. At that time, the charge nurse will assess the resident for change of condition, report to family and physician and carry out any new orders received. Director of Nursing/designee reviews a report from the Kiosk Monday through Friday and the weekend RN will run report to review output of residents with Foley catheter to review urine output documentation. Any missing documentation on urine output of resident ' s with Foley catheters has been addressed and a late entry made in the chart to reflect urine output for any missing documentation. A line has been added on the Nurses ' Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. As of 3/26/13 at 11:30 a.m. all current incontinent residents have been assessed for any signs and symptoms of urinary tract infection. One resident on the east side had no change in urine odor, vital signs stable, but complained of lower back pain. Physician notified of complaint and order received for lab urinalysis and culture and sensitivity. Family has been notified of complaint and new order. One resident on the west side had vital signs within normal limits, no complaints, but did have a change in urine odor. Physician has been notified of this change. Resident is aware of the call to the physician. These assessments and findings have been documented in the resident ' s medical record. Resident on east side with Foley catheter was assessed and a physician order [REDACTED]. Family notified. Catheter has been discontinued and resident is voiding without difficulty. Post void residual of 30 cc (cubic centimeters) was obtained via straight catheter per physician's order [REDACTED]. Certified nursing assistants are toileting the resident and she is voiding on the toilet. Certified nursing assistants are reporting results to nurse. This resident will be reassessed using the Bladder Assessment to determine continence and care plans will be developed based upon results. The Medical Director has been made aware of the alleged deficient practice and plans in place to correct. The Performance Improvement Committee will review the above actions taken by the facility to correct the alleged deficient practice. The Director of Nursing will report progress to the Performance Improvement Committee monthly for three months and then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions. On 3/27/13 at 11:00 a.m. the Immediate Jeopardy was lowered to a scope and severity of actual harm that is not Immediate Jeopardy level at a pattern. CMS Form 672 dated 3/21/13 documented four residents having an indwelling urinary catheter, upon observation, there was only one resident with an indwelling urinary catheter besides Resident #3.

Based on observation, interview and record review the facility failed to develop and maintain an infection control program designed to prevent the transmission of infection. The facility failed to ensure: - Eight identified urinary tract infections in January, 2013 - Nine identified urinary tract infections in February, 2013 - Two identified urinary tract infections in March, 2013 This deficient practice could affect 45 residents, identified by the facility as being incontinent of urine placed at increased risk for infection, increase risk of unnecessary antibiotic use, and decreased quality of life. The findings included: An Immediate Jeopardy was identified on 3/22/13 at 10:45 a.m. with the Administrator, DON and RNC #1 present. While the Immediate Jeopardy was removed 3/27/13 at 11:00 a.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Forty-five facility identified incontinent residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of the facility's Policy and Procedure "Infection Preventionand Control" dated 9/2011 documented "......The Infection Prevention and Control/Epidemiology Program is a facility policy and Procedure....Infection Prevention and Control Programs are an integral part of the Facility's philosophy and procedures related to patient/resident care....Facility recognizes that quality Infection Prevention and Control Programs administrered by a qualified Infection Preventionist will lead to better patient/resident care, reduce healthcare acquired illness and result in resource conservation......A quality infection prevention and control program will provide direction regarding outcome monitoring, patient/resident welfare, and employee based monitoring and care, and a general overall concern for the facility community...." In an interview on 3/25/13 at 10:20 a.m. ADON #2 stated that the nurse who had been doing infection control left in January 2013 and that she (ADON #2) had been trying "to keep up with it" . She said she was not aware that Proteus Mirabalis was a fecal bacterium. She was not aware of any recent in-services on incontinent care. In an interview on 3/21/13 at 11:30 a.m. ADON #2 stated that ".....evidently I really know my residents ...." When asked to see the residents that was on the CMS Form 672 dated 3/21/13 that documented the facility having four residents in the facility as having a Foley catheter. Observation at this time revealed only one other resident (Resident #1) as having an indwelling urinary catheter. Resident #12 had not had a Foley catheter "....for the past three weeks, she pulled her catheter out and hospice said to leave it out ...." There was no evidence of documentation of a physician order [REDACTED]. Resident #6 had not had a catheter since before 10/5/13 when hospice performed an in and out catherization to obtain urine for a urinalysis and culture and sensitivity for a suspected urinary tract infection. There was no evidence of documentation of an order to take or leave the catheter out. Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for eight of 17 residents (Resident #1, #2, #3, #7,#8, #9, #11 and #12). Forty-five facility identified incontinent residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. An Immediate Jeopardy was identified on 3/22/13 at 10:45 a.m. While the Immediate Jeopardy was removed 3/27/13 at 11:00 a.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Seventy-one residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #3 ' s clinical record " Resident Admission Record " documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/29/11 documented she was admitted to the facility with an indwelling Foley catheter with a wound vac to her coccyx. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 6/8/12 documented her Stage IV pressure ulcer to her coccyx had closed. Review of Resident #3 ' s clinical record there was no evidence of documentation of any calls to her physician or attempts to remove the Foley catheter since wound healing. Review of Resident #3 ' s clinical record " Minimum Data Set (MDS) " dated 2/17/13 documented under Speech Clarity Resident #3 was documented as having no speech - absence of spontaneous speech. Under Cognitive Skills for Daily Decision Making, it was documented as severely impaired - never/rarely made decisions. Under Functional Status, Bed Mobility, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Transfer, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Locomotion on Unit, Dressing, Toilet Use, Personal Hygiene, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Bladder and Bowel, Resident #3 was documented as having an indwelling Foley catheter for urine elimination and Ostomy for bowel movements. Review of Resident #3 ' s clinical record " Care Plan " dated 2/28/13 documented under Problem documented " .....I have a potential for compromised psychosocial well-being due to being a bed bound resident in the facility I reside in .... " Problem documented " ....Due to my health status I stay in my room. I like to listen to music or the TV. I need assistance turning the TV on, or on the radio, occasionally I attend to special events, and also I enjoy my family visits ..... " Problem documented " .....I am bedfast and my cognitive status/decision making skills are impaired ....I require extensive to total assistance with ADL ' s (Activities of Daily Living) .....Under Goal documented " ....I will have my needs anticipated and met by staff for 90 days .... " Review of Resident #3 ' s clinical record " Physician ' s Progress Notes " dated 3/19/13 untimed, documented " .....staff reported patient vomited twice over night ....up in wheelchair ....alert, no fever, no acute distress, will watch ....[MEDICATION NAME] (anti-emetic used for nausea/vomiting) prn (as needed) ... .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/18/13 at 2310 (11:10 p.m.) documented by LVN #7 " .....resident vomited times one, [MEDICATION NAME] as needed 25 mg po (by mouth) given ....HOB (head of bed) elevated ....physician notified ..... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0300 (3:00 a.m.) documented by LVN #7 " ... ...feeding resident, vomited again and physician ' s office notified .....order hold feeding and give [MEDICATION NAME] 25 mg po (per oral or by mouth) .... Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0800 (8:00 a.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....respirations regular and non-labored, lung sounds clear to auscultation in front and back .....abdomen soft and non-distended ... ...bowel sounds in four quadrants ... ...[DEVICE] (an artificial opening on the abdomen that enters the stomach for the purpose of liquid feeding formula) patent and intact .....no signs/symptoms of aspiration noted .....Placement checked, no residual noted ....breakfast feedings held due to patient ate 50% of meal .....family called and notified about resident vomiting last night .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 10:00 a.m. documented by LVN #2 " ... ...resident resting in bed with eyes open, respirations regular and non-labored, lung sounds clear to auscultation in front and back .....[DEVICE] patent and intact ....Foley catheter patent and draining clear yellow urine ....colostomy patent with soft stool in bag .....HOB elevated ...no distress noted at this time ... ... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 12:35 p.m. documented by LVN #2 " ... ...physician here to assess resident .....see progress notes .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 1340 (1:40 p.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....HOB elevated ....Vital Signs (VS) blood pressure 118/54, heart rate 135, respirations 36, temperature 96.5, oxygen saturation 96%...accu-check (a finger stick used to collect blood to measure blood glucose (sugar) levels) 235 .....responding slightly to verbal stimuli ...diaphoretic and tachycardiac .....lung sounds clear to auscultation, no nausea/vomiting noted ....Foley catheter patent draining clear yellow urine, [DEVICE] patent ....colostomy patent with soft stool present .....send resident to emergency department for evaluation and treatment .....physician and family notified ..... " Record review of the local EMS (emergency medical services) " Run Sheet " dated 3/19/13 beginning at 1418 (2:18 p.m.) and ending at the local emergency department at 1432 (2:42 p.m.), when arrived at the local emergency department, documented " ....staff states patient vomited twice previously .....requesting transport for possible aspiration - patient has history of severe dementia .....tachypnea (rapid breathing), tachycardia (rapid heart rate) hypotension (low blood pressure) and diaphoresis (sweating) .....patient transferred to EMS cot via three person lift ....IV attempt twice was unsuccessful ....impression - septic shock ..... " Review of the EMS " Run Sheet " dated 3/19/13 at 1418 (2:18 p.m.) the first set of vital signs were documented the blood pressure as 89/53, pulse 134, respirations 20. Observation on 3/21/13 at 9:00 a.m. at the local hospital Intensive Care Unit revealed Resident #3 had a large unstageable pressure sore on her right heel. In an interview on 3/22/13 at 1:10 p.m. the Emergency Department Registered Nurse that received Resident #3 into the emergency department stated that when she received Resident #3 from the emergency medical services, Resident #3 was not alert, her rectal temperature was elevated and her Foley catheter was draining thick gray pus. She stated that Resident #3 was in a very bad state, diaphoretic (soaked in sweat) and had a general bad odor about her. She stated that Resident #3 was very dirty when she arrived to the emergency room . In an interview on 3/21/13 at 8:15 a.m. Intensive Care Unit (ICU) nurse (ICU nurse #1) that had care for Resident #3 when she was first admitted to the ICU stated that when she received Resident #3 from the emergency room , that Resident #3 was filthy and her Foley catheter had sludge in the tubing clotting off the urine from going into the drainage collection bag. She described the urine as cloudy, nasty green/gray in color and when she removed the Foley that she came to the hospital with from the facility, the tubing was stained and dirty. ICU nurse #1 described that when she removed the old Foley, there were three ICU nurses in the room assisting and two of the ICU nurse ' s had to leave the room vomiting from the overwhelming odor of the urine that saturated the bedding of Resident #3. She stated that after placing a new Foley catheter in Resident #3 and after Resident #3 urinated and soaked the entire bed, Resident #3 voided almost 500 cc (cubic centimeters) of cloudy, dark, thick urine. She stated that Resident #3 had dried stool on her buttocks and abdomen. She stated that she had given Resident #3 two head to toe bed baths during her shift and Resident #3 still was not clean when she turned over care to the oncoming nurse. In an interview on 3/25/13 at 10:50 a.m. Intensive Care Unit (ICU) nurse #2 that took over care of Resident #3 stated that she also gave Resident #3 two complete head to toe bed baths and finally got her cleaned up. She stated that she had called the facility asking when Resident #3 ' s Foley catheter was last changed and the DON told her that it was 2/25/13. The ICU nurse stated that she also informed the DON at the facility that when Resident #3 arrived, she was filthy and her urine was thick, gray sludge and wanted to know how Resident #3 had been cared for. In an interview on 3/21/13 at 8:30 a.m. Resident #3 ' s four daughters were present and stated that the first time they heard of their mother being admitted to the intensive care unit (ICU) was 3/19/13 at night (they were not sure at what time, but it was late evening) when the ICU nurse called them to come see their mother, that she was in critical condition and was not expected to survive. The daughters stated that they had called the facility and spoken with the Administrator and DON about their care concerns for Resident #3. The daughters stated that they had placed a sign above their mother ' s bed with times to be up in the Geri-chair and when to be placed back in bed. They stated that often times their mother would be in the same clothes for several days at a time, that her eyes were frequently matted and the CNA ' s would often leave her dirty frequently. They also stated that there was one CNA that manually picked their mother up from the Geri-chair by herself and placed their mother onto the bed. They stated that their mother was to be transferred by the Hoyer lift only and with two person assist. Review of the local hospital ' s medical records for Resident #3 documented by the first ICU nurse on 3/19/13 at 2100 (9:00 p.m.) documented " ... ....Patient Diagnosis: [REDACTED]..catheter removed and replaced on admission ....Patient voided a large amount of urine incontinently immediately after catheter was removed ... ...urine foul smelling, dark, cloudy and concentrated ....New Foley catheter inserted ..... " Review of the local hospitals medical records for Resident #3 documented by the first ICU nurse on 3/21/13 at 8:00 a.m. " ... ....I received the patient 3/19/13 and her Foley catheter appeared extremely dirty ....urine was very cloudy, a grey-amber color and had an overwhelmingly foul odor ....There was minimal urine output in the bag and urine was stationary in the tubing .....Upon taking out the Foley catheter, patient voided a great amount of urine described above ...after inserting the new catheter, patient immediately had out 450cc of urine described above ....patient was very unclean .... " Review of the hospital ' s " Patient Results " dated 3/19/13 at 1531 (3:51 p.m.) documented the culture and sensitivity (C&S) results as Proteus Mirabilis and Escherichia Coli (both are bacteria commonly found in feces {stool}). Observation on 3/21/13 at 7:50 a.m. at the local hospital Intensive Care Unit (ICU) revealed that Resident #3 had an Indwelling Foley Catheter draining thick, dark amber urine. The ICU nurse caring for Resident #3 stated that the urine looked " so much better " than when she first received her. At this time, Resident #3 was being transferred to another unit at the hospital. Observation on 3/21/13 at 8:45 a.m. at the local hospital in a regular hospital room revealed Resident #3 had an unstageable pressure ulcer located on her right heel that the facility had no evidence of documentation. Also she had two stage II pressure ulcers on the lateral aspect of her right foot. In an interview on 3/22/13 at 10:10 a.m. LVN #3 stated that she had changed the indwelling urinary catheter on Resident #3 on 2/25/13 when she was still working nights. She stated that the nurse working on the west side stated she did not know how to change an indwelling urinary catheter on a resident that was contracted. LVN #3 stated that the old urinary catheter had sediment in the tubing clogging off the flow of urine into the collection bag. LVN #3 stated that when she placed the new indwelling urinary catheter it immediately began draining without any difficulties. LVN #3 stated that she did not detect any odor about Resident #3 or the urine when she changed the catheter on 2/25/13. LVN #3 stated that she did not notify the physician due to the amount of sediment in the catheter tubing. LVN #3 stated that in her professional opinion indwelling urinary catheters should be changed at least once a month or more often if needed. LVN #3 stated in her professional opinion that it would take a very long time for urine to go from clear yellow to thick gray sludge, she was unable to give an estimate on how long it would take. In an interview on 3/21/13 at 11:30 a.m. ADON #2 accompanied this investigator to see the residents that was on the CMS Form 672 dated 3/21/13 that documented the facility having four residents in the facility as having a Foley catheter. Observation at this time revealed only one other resident (Resident #1) as having an indwelling urinary catheter. Resident #12 had not had a Foley catheter " ....for the past three weeks, she pulled her catheter out and hospice said to leave it out .... " There was no evidence of documentation of a physician order [REDACTED]. Resident #6 had not had a catheter since before 10/5/13 when hospice performed an in and out catherization to obtain urine for a urinalysis and culture and sensitivity for a suspected urinary tract infection. ADON #2 stated sarcastically " ....evidently I really know my residents ..... " There was no evidence of documentation of an order to take or leave the catheter out. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that in her professional opinion Foley catheters should be changed monthly. She also stated that some nurse aides measure the urine and document it and some aides only document urine amounts as small, medium or large. In an interview on 3/22/13 at 10:45 a.m. ADON #2 stated that the assessment completed on Resident #3 was a wrong assessment because the nurse did not do a head to toe assessment and the documentation on the assessment documented Resident #3 ' s urine as clear yellow urine. She stated that LVN#2 did not do a complete assessment of Resident #3 due to the fact that LVN #2 had not documented in Resident #3 ' s clinical record regarding the color and clarity of Resident #3 ' s urine until 3/19/13. In an interview on 3/25/13 at 11:39 a.m. CNA #3 stated that she had emptied Resident #3 ' s drainage bag on 3/19/13 before she went off shift at 6:00 a.m. and at that time the urine in the drainage bag was yellow and had bacteria in it. She explained that by having bacteria in the urine she meant that the urine was white and cloudy and to her it looked like this white cloudy stuff was clogging the tubing. She stated that she reported it to the day nurse who was LVN #2. In an interview on 3/22/13 at 11:00 a.m. LVN #2 stated that Resident #3 had vomited twice the night before (3/18/13) she was sent to the hospital. He stated that Resident #3 ate breakfast in bed but did not eat any lunch. The physician saw her and said she was fine. A few hours later (approximately 55 minutes) she started sweating a lot and her pulse rate got fast. LVN #2 stated that Resident #3 was mumbling and not doing the stuff she normally does. After lunch she was not responding, was breathing fast and was sweaty. LVN #2 described Resident #3 ' s urine as being yellow, clear and draining, but he was unable to state how much he observed in the bag at the time of the transfer. In an interview on 3/22/13 at 11:10 a.m. LVN #1 stated that if a resident with a urinary catheter had appeared to have a urinary tract infection it would be best to go ahead and change the catheter, even if waiting on a urinalysis. In an interview on 3/22/13 at 11:15 a.m. LVN #1 stated there were no open areas on Resident #3 ' s feet and that he had assess her skin the morning prior to her being sent to the emergency department and that he did not look at her urine. In an interview on 3/22/13 at 12:20 p.m. the Medical Director for the facility stated that he was unaware that the facility had changed their policy of changing indwelling urinary catheters monthly to as needed. He stated that in his professional medical opinion, urinary catheters needed to be changed at least once a month or sooner if needed. He stated that " .....I just don ' t know what to do with that facility .... " In an interview on 3/22/13 at 3:05 p.m. the DON stated that she tracks bowel movements, oral and [DEVICE] administered intakes. She stated that she does not see anything on outputs (such as urine). She stated that the system goes down every day at 2:00 a.m. and 2:00 p.m. but it does not stay down for very long (she was unable to give an estimated amount of time the system would be down). She stated that she had been training staff on fluid intake. In an interview on 3/22/13 at 3:15 p.m. CNA #5 stated that when she worked with Resident #3 on 3/18/13 the urine was dark yellow and she did not think anything of it because since her employment began in August 2012, Resident #3 ' s urine had always been dark yellow with " stuff " in the tubing. CNA #5 stated that the reason she did not tell any of the charge nurses about the color and clarity of Resident #3 ' s urine was because the urine hadn ' t changed since she had begun working in August, 2012. In an interview on 3/22/13 at 3:25 p.m. CNA #6 stated that she would go and ask the nurse how to input color, consistency and amount of urine into the kiosk. She stated that it was very important to keep the catheter clean and to be very careful while completing peri-care because it they didn ' t want to give the residents who have indwelling urinary catheters an infection. In an interview on 3/24/13 at 8:20 a.m. RN #1 stated that she worked weekends, but had been off and had not worked with Resident #3 for over a month. During the interview she said that in her professional opinion indwelling urinary catheters should be change done a month or sooner if needed. RN #1 was no aware of any facility criteria for changing out urinary catheters. In an interview on 3/25/13 at 10:20 a.m. ADON #2 stated that the nurse who had been doing infection control left in January 2013 and that she (ADON #2) had been trying " to keep up with it " . She said she was not aware that Proteus Mirabalis was a fecal bacterium. She was not aware of any recent in-services on incontinent care. In an interview on 3/25/13 at 1:30 p.m. CNA #2 stated that the last time she had taken care (which was documented on the kiosk as 3/10/13) of Resident #3 she reported to the nurse that the urine was a dark brown color and that she did inform the charge nurse, but was unable to state which nurse she had reported this to. CNA #2 stated that it was the day charge nurse for the west side. Review of the facility ' s Infection Reports revealed two forms being used. One contained the questions " Health Care Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " which had yes or no answers. The second Infection Report Form documented " ....Facility Acquired Infection developed after admission? " and " Community Acquired Evidence of Infection at time of admission? " Both with yes or no answers. Seventeen Infection Reports of residents with UTI ' s were reviewed for whether they were marked to indicate if the UTI was an HAI or CAI. Nine of the reports had both questions marked " No " , seven had neither question answered, and one had HAI question left blank and answered " No " on the CAI question. In an interview on 3/26/13 at 10:50 a.m. with the DON, ADON #2 and RNC #1, RNC #1 stated that there were criteria for determining if a resident infection was a Healthcare Associated Infection (HAI) and ADON #2 pointed to the criteria listed on the HAI form. In an interview on 3/26/13 at 3:50 p.m. and 4:30 p.m. RNC #2 stated that on the Infection Report form the questions " Healthcare Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " should be answered either yes or no. If the HAI question is answered " yes " , then the Healthcare Associated Infection Surveillance Report Form should be filled out. RNC #2 stated that the Infection Control Policy criteria was to determine if there was an infection and the HAI Surveillance Report Form criteria was to help determine if the infection was chronic or acute. Review of the facility's Policy and Procedure for when to change an indwelling urinary catheter was a handout printed off of the internet from HICPAC (Healthcare Infeciton Control Practices Advisory Committe) - Guideline for Prevention of Catheter-Associated Urinary Tract Infections dated 2009 documented ".....changing an indwelling catheters or drainage bags at routine, fixed intervals is not recomended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised....Category II...." Review of "Category II" documented ".....a weak recommendation supported by any quality evidence suggesting a tradeoff between clinical benefits and harms....." This document wsa given as the facility policy and procedure for indwelling urinary catheter changes by RNC #1. RNC #1 stated that the corporation adopted this as their policy and procedure in August 2012 and the facilities had put this suggestion into place at that time. In an interview on 3/27/13 at 9:30 a.m. ADON #2 stated that she had no instruction on how to fill out the Infection Control Log. Review of Resident #1 ' s clinical record " Admission Record " undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Observation on 3/22/12 at 9:15 a.m. CNA #7 providing incontinent care to Resident #1 revealed CNA #7 rubbing back and forth with the same piece of cloth on the urinary catheter. CNA #7 then cleaned stool from an incontinent episode of bowel movement from the bottom up, spreading stool to vaginal/peri area. Observation on 3/21/13 at 3:40 p.m. revealed that Resident #1 ' s urinary catheter tubing contained dark amber urine with sediment in the tubing. ADON #2 stated that she thought the urine was yellow, but when questioned, she stated that she would call the urine amber. ADON #2 stated that with the sediment in the tubing and the color of the urine, she thought that Resident #1 might have a urinary tract infection. Review of Resident #1 ' s clinical record " Diagnostics " dated 3/19/13 documented Resident #1 ' s urine contained the bacterium Escherichia coli (which is intestinal bacteria). Review of Resident #2 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]., hypertension and osteoarthrosis. Review of Resident #2 ' s clinical record " Diagnostics " dated 1/23/13 document her urine contained Escherichia coli, [MEDICATION NAME] cloacae, and proteus mirabilis which is commonly found in the intestines or fecal material. Review of Resident #7 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #7 ' s clinical record " Diagnostics " dated 2/7/13 documented her urinalysis and culture and sensitivity contained Escherichia Coli which is intestinal bacteria. Review of Resident #8 ' s admission record undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #8 ' s clinical record " Diagnostics " dated 1/12/13 documented her urinalysis and culture and sensitivity contained Proteus mirabilis which is intestinal bacteria. Review of Resident #9 ' s admission record revealed she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9 ' s clinical record " Diagnostics " dated 2/5/13 documented her urinalysis and culture and sensitivity contained [MEDICATION NAME] Faecalis which is intestinal bacteria. Review of Resident #11 ' s admission record revealed he was an [AGE] year old male who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #11 ' s clinical record " Nurse ' s Notes " documented he was admitted to the facility on [DATE] with an indwelling urinary catheter. On the date of admission (3/14/13) at 6:40 p.m. he pulled the catheter out and it was re-inserted by nursing staff. Review of Resident #11 ' s clinical record " Admission Order " revealed no evidence of documentation for an indwelling urinary catheter. Review of Resident #11 ' s clinical record " Physician order [REDACTED]. Review of Resident #12 ' s clinical record " Resident Admission Record " undated documented that she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12 ' s clinical record " Nurse ' s Notes " dated 3/11/13 at 0840 (8:40 a.m.) documented " ... ...hospice notified the time of resident pulling out Foley catheter on previous shift, awaiting new orders(to be) calle

Based on observations, interviews and record reviews, the facility failed to ensure one of two residents (Resident #3) clinical condition demonstrated that urinary catherization was medically necessary. Resident #3 did not have a clinical [DIAGNOSES REDACTED]. This failure could contribute to loss of bladder control and urinary tract infections for Resident #3 and could likely affect 45 other residents identified by the facility as being frequently or occasionally incontinent of urine. An Immediate Jeopardy was identified on 3/22/13 at 10:45 a.m. with the Administrator, DON and RNC #1 present. While the Immediate Jeopardy was removed 3/27/13 at 11:00 a.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Seventy-one residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #3 ' s clinical record " Resident Admission Record " documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/29/11 documented she was admitted to the facility with an indwelling Foley catheter with a wound vac to her coccyx. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 6/8/12 documented her Stage IV pressure ulcer to her coccyx had closed. Review of Resident #3 ' s clinical record there was no evidence of documentation of any calls to her physician or attempts to remove the Foley catheter since wound healing. Review of Resident #3 ' s clinical record " Minimum Data Set (MDS) " dated 2/17/13 documented under Speech Clarity Resident #3 was documented as having no speech - absence of spontaneous speech. Under Cognitive Skills for Daily Decision Making, it was documented as severely impaired - never/rarely made decisions. Under Functional Status, Bed Mobility, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Transfer, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Locomotion on Unit, Dressing, Toilet Use, Personal Hygiene, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Bladder and Bowel, Resident #3 was documented as having an indwelling Foley catheter for urine elimination and Ostomy for bowel movements. Review of Resident #3 ' s clinical record " Care Plan " dated 2/28/13 documented under Problem documented " .....I have a potential for compromised psychosocial well-being due to being a bed bound resident in the facility I reside in .... " Problem documented " ....Due to my health status I stay in my room. I like to listen to music or the TV. I need assistance turning the TV on, or on the radio, occasionally I attend to special events, and also I enjoy my family visits ..... " Problem documented " .....I am bedfast and my cognitive status/decision making skills are impaired ....I require extensive to total assistance with ADL ' s (Activities of Daily Living) .....Under Goal documented " ....I will have my needs anticipated and met by staff for 90 days .... " Review of Resident #3 ' s clinical record " Physician ' s Progress Notes " dated 3/19/13 untimed, documented " .....staff reported patient vomited twice over night ....up in wheelchair ....alert, no fever, no acute distress, will watch ....[MEDICATION NAME] (anti-emetic used for nausea/vomiting) prn (as needed) ... .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/18/13 at 2310 (11:10 p.m.) documented by LVN #7 " .....resident vomited times one, [MEDICATION NAME] as needed 25 mg po (by mouth) given ....HOB (head of bed) elevated ....physician notified ..... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0300 (3:00 a.m.) documented by LVN #7 " ... ...feeding resident, vomited again and physician ' s office notified .....order hold feeding and give [MEDICATION NAME] 25 mg po (per oral or by mouth) .... Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0800 (8:00 a.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....respirations regular and non-labored, lung sounds clear to auscultation in front and back .....abdomen soft and non-distended ... ...bowel sounds in four quadrants ... ...[DEVICE] (an artificial opening on the abdomen that enters the stomach for the purpose of liquid feeding formula) patent and intact .....no signs/symptoms of aspiration noted .....Placement checked, no residual noted ....breakfast feedings held due to patient ate 50% of meal .....family called and notified about resident vomiting last night .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 10:00 a.m. documented by LVN #2 " ... ...resident resting in bed with eyes open, respirations regular and non-labored, lung sounds clear to auscultation in front and back .....[DEVICE] patent and intact ....Foley catheter patent and draining clear yellow urine ....[MEDICAL CONDITION] patent with soft stool in bag .....HOB elevated ...no distress noted at this time ... ... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 12:35 p.m. documented by LVN #2 " ... ...physician here to assess resident .....see progress notes .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 1340 (1:40 p.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....HOB elevated ....Vital Signs (VS) blood pressure 118/54, heart rate 135, respirations 36, temperature 96.5, oxygen saturation 96%...accu-check (a finger stick used to collect blood to measure blood glucose (sugar) levels) 235 .....responding slightly to verbal stimuli ...diaphoretic and [MEDICAL CONDITION] .....lung sounds clear to auscultation, no nausea/vomiting noted ....Foley catheter patent draining clear yellow urine, [DEVICE] patent ....[MEDICAL CONDITION] patent with soft stool present .....send resident to emergency department for evaluation and treatment .....physician and family notified ..... " Record review of the local EMS (emergency medical services) " Run Sheet " dated 3/19/13 beginning at 1418 (2:18 p.m.) and ending at the local emergency department at 1432 (2:42 p.m.), when arrived at the local emergency department, documented " ....staff states patient vomited twice previously .....requesting transport for possible aspiration - patient has history of severe dementia .....tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate) [MEDICAL CONDITION] (low blood pressure) and diaphoresis (sweating) .....patient transferred to EMS cot via three person lift ....IV attempt twice was unsuccessful ....impression - septic shock ..... " Review of the EMS " Run Sheet " dated 3/19/13 at 1418 (2:18 p.m.) the first set of vital signs were documented the blood pressure as 89/53, pulse 134, respirations 20. Observation on 3/21/13 at 9:00 a.m. at the local hospital Intensive Care Unit revealed Resident #3 had a large unstageable pressure sore on her right heel. In an interview on 3/22/13 at 1:10 p.m. the Emergency Department Registered Nurse that received Resident #3 into the emergency department stated that when she received Resident #3 from the emergency medical services, Resident #3 was not alert, her rectal temperature was elevated and her Foley catheter was draining thick gray pus. She stated that Resident #3 was in a very bad state, diaphoretic (soaked in sweat) and had a general bad odor about her. She stated that Resident #3 was very dirty when she arrived to the emergency room . In an interview on 3/21/13 at 8:15 a.m. Intensive Care Unit (ICU) nurse (ICU nurse #1) that had care for Resident #3 when she was first admitted to the ICU stated that when she received Resident #3 from the emergency room , that Resident #3 was filthy and her Foley catheter had sludge in the tubing clotting off the urine from going into the drainage collection bag. She described the urine as cloudy, nasty green/gray in color and when she removed the Foley that she came to the hospital with from the facility, the tubing was stained and dirty. ICU nurse #1 described that when she removed the old Foley, there were three ICU nurses in the room assisting and two of the ICU nurse ' s had to leave the room vomiting from the overwhelming odor of the urine that saturated the bedding of Resident #3. She stated that after placing a new Foley catheter in Resident #3 and after Resident #3 urinated and soaked the entire bed, Resident #3 voided almost 500 cc (cubic centimeters) of cloudy, dark, thick urine. She stated that Resident #3 had dried stool on her buttocks and abdomen. She stated that she had given Resident #3 two head to toe bed baths during her shift and Resident #3 still was not clean when she turned over care to the oncoming nurse. In an interview on 3/25/13 at 10:50 a.m. Intensive Care Unit (ICU) nurse #2 that took over care of Resident #3 stated that she also gave Resident #3 two complete head to toe bed baths and finally got her cleaned up. She stated that she had called the facility asking when Resident #3 ' s Foley catheter was last changed and the DON told her that it was 2/25/13. The ICU nurse stated that she also informed the DON at the facility that when Resident #3 arrived, she was filthy and her urine was thick, gray sludge and wanted to know how Resident #3 had been cared for. In an interview on 3/21/13 at 8:30 a.m. Resident #3 ' s four daughters were present and stated that the first time they heard of their mother being admitted to the intensive care unit (ICU) was 3/19/13 at night (they were not sure at what time, but it was late evening) when the ICU nurse called them to come see their mother, that she was in critical condition and was not expected to survive. The daughters stated that they had called the facility and spoken with the Administrator and DON about their care concerns for Resident #3. The daughters stated that they had placed a sign above their mother ' s bed with times to be up in the Geri-chair and when to be placed back in bed. They stated that often times their mother would be in the same clothes for several days at a time, that her eyes were frequently matted and the CNA ' s would often leave her dirty frequently. They also stated that there was one CNA that manually picked their mother up from the Geri-chair by herself and placed their mother onto the bed. They stated that their mother was to be transferred by the Hoyer lift only and with two person assist. Review of the local hospital ' s medical records for Resident #3 documented by the first ICU nurse on 3/19/13 at 2100 (9:00 p.m.) documented " ... ....Patient Diagnosis: [REDACTED]..catheter removed and replaced on admission ....Patient voided a large amount of urine incontinently immediately after catheter was removed ... ...urine foul smelling, dark, cloudy and concentrated ....New Foley catheter inserted ..... " Review of the local hospitals medical records for Resident #3 documented by the first ICU nurse on 3/21/13 at 8:00 a.m. " ... ....I received the patient 3/19/13 and her Foley catheter appeared extremely dirty ....urine was very cloudy, a grey-amber color and had an overwhelmingly foul odor ....There was minimal urine output in the bag and urine was stationary in the tubing .....Upon taking out the Foley catheter, patient voided a great amount of urine described above ...after inserting the new catheter, patient immediately had out 450cc of urine described above ....patient was very unclean .... " Review of the hospital ' s " Patient Results " dated 3/19/13 at 1531 (3:51 p.m.) documented the culture and sensitivity (C&S) results as Proteus Mirabilis and Escherichia Coli (both are bacteria commonly found in feces {stool}). Observation on 3/21/13 at 7:50 a.m. at the local hospital Intensive Care Unit (ICU) revealed that Resident #3 had an Indwelling Foley Catheter draining thick, dark amber urine. The ICU nurse caring for Resident #3 stated that the urine looked " so much better " than when she first received her. At this time, Resident #3 was being transferred to another unit at the hospital. Observation on 3/21/13 at 8:45 a.m. at the local hospital in a regular hospital room revealed Resident #3 had an unstageable pressure ulcer located on her right heel that the facility had no evidence of documentation. Also she had two stage II pressure ulcers on the lateral aspect of her right foot. In an interview on 3/22/13 at 10:10 a.m. LVN #3 stated that she had changed the indwelling urinary catheter on Resident #3 on 2/25/13 when she was still working nights. She stated that the nurse working on the west side stated she did not know how to change an indwelling urinary catheter on a resident that was contracted. LVN #3 stated that the old urinary catheter had sediment in the tubing clogging off the flow of urine into the collection bag. LVN #3 stated that when she placed the new indwelling urinary catheter it immediately began draining without any difficulties. LVN #3 stated that she did not detect any odor about Resident #3 or the urine when she changed the catheter on 2/25/13. LVN #3 stated that she did not notify the physician due to the amount of sediment in the catheter tubing. LVN #3 stated that in her professional opinion indwelling urinary catheters should be changed at least once a month or more often if needed. LVN #3 stated in her professional opinion that it would take a very long time for urine to go from clear yellow to thick gray sludge, she was unable to give an estimate on how long it would take. In an interview on 3/21/13 at 11:30 a.m. ADON #2 accompanied this investigator to see the residents that was on the CMS Form 672 dated 3/21/13 that documented the facility having four residents in the facility as having a Foley catheter. Observation at this time revealed only one other resident (Resident #1) as having an indwelling urinary catheter. Resident #12 had not had a Foley catheter " ....for the past three weeks, she pulled her catheter out and hospice said to leave it out .... " There was no evidence of documentation of a physician order [REDACTED]. Resident #6 had not had a catheter since before 10/5/13 when hospice performed an in and out catherization to obtain urine for a urinalysis and culture and sensitivity for a suspected urinary tract infection. ADON #2 stated sarcastically " ....evidently I really know my residents ..... " There was no evidence of documentation of an order to take or leave the catheter out. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that in her professional opinion Foley catheters should be changed monthly. She also stated that some nurse aides measure the urine and document it and some aides only document urine amounts as small, medium or large. In an interview on 3/22/13 at 10:45 a.m. ADON #2 stated that the assessment completed on Resident #3 was a wrong assessment because the nurse did not do a head to toe assessment and the documentation on the assessment documented Resident #3 ' s urine as clear yellow urine. She stated that LVN#2 did not do a complete assessment of Resident #3 due to the fact that LVN #2 had not documented in Resident #3 ' s clinical record regarding the color and clarity of Resident #3 ' s urine until 3/19/13. In an interview on 3/25/13 at 11:39 a.m. CNA #3 stated that she had emptied Resident #3 ' s drainage bag on 3/19/13 before she went off shift at 6:00 a.m. and at that time the urine in the drainage bag was yellow and had bacteria in it. She explained that by having bacteria in the urine she meant that the urine was white and cloudy and to her it looked like this white cloudy stuff was clogging the tubing. She stated that she reported it to the day nurse who was LVN #2. In an interview on 3/22/13 at 11:00 a.m. LVN #2 stated that Resident #3 had vomited twice the night before (3/18/13) she was sent to the hospital. He stated that Resident #3 ate breakfast in bed but did not eat any lunch. The physician saw her and said she was fine. A few hours later (approximately 55 minutes) she started sweating a lot and her pulse rate got fast. LVN #2 stated that Resident #3 was mumbling and not doing the stuff she normally does. After lunch she was not responding, was breathing fast and was sweaty. LVN #2 described Resident #3 ' s urine as being yellow, clear and draining, but he was unable to state how much he observed in the bag at the time of the transfer. In an interview on 3/22/13 at 11:10 a.m. LVN #1 stated that if a resident with a urinary catheter had appeared to have a urinary tract infection it would be best to go ahead and change the catheter, even if waiting on a urinalysis. In an interview on 3/22/13 at 11:15 a.m. LVN #1 stated there were no open areas on Resident #3 ' s feet and that he had assess her skin the morning prior to her being sent to the emergency department and that he did not look at her urine. In an interview on 3/22/13 at 12:20 p.m. the Medical Director for the facility stated that he was unaware that the facility had changed their policy of changing indwelling urinary catheters monthly to as needed. He stated that in his professional medical opinion, urinary catheters needed to be changed at least once a month or sooner if needed. He stated that " .....I just don ' t know what to do with that facility .... " In an interview on 3/22/13 at 3:05 p.m. the DON stated that she tracks bowel movements, oral and [DEVICE] administered intakes. She stated that she does not see anything on outputs (such as urine). She stated that the system goes down every day at 2:00 a.m. and 2:00 p.m. but it does not stay down for very long (she was unable to give an estimated amount of time the system would be down). She stated that she had been training staff on fluid intake. In an interview on 3/22/13 at 3:15 p.m. CNA #5 stated that when she worked with Resident #3 on 3/18/13 the urine was dark yellow and she did not think anything of it because since her employment began in August 2012, Resident #3 ' s urine had always been dark yellow with " stuff " in the tubing. CNA #5 stated that the reason she did not tell any of the charge nurses about the color and clarity of Resident #3 ' s urine was because the urine hadn ' t changed since she had begun working in August, 2012. In an interview on 3/22/13 at 3:25 p.m. CNA #6 stated that she would go and ask the nurse how to input color, consistency and amount of urine into the kiosk. She stated that it was very important to keep the catheter clean and to be very careful while completing peri-care because it they didn ' t want to give the residents who have indwelling urinary catheters an infection. In an interview on 3/24/13 at 8:20 a.m. RN #1 stated that she worked weekends, but had been off and had not worked with Resident #3 for over a month. During the interview she said that in her professional opinion indwelling urinary catheters should be change done a month or sooner if needed. RN #1 was no aware of any facility criteria for changing out urinary catheters. In an interview on 3/25/13 at 10:20 a.m. ADON #2 stated that the nurse who had been doing infection control left in January 2013 and that she (ADON #2) had been trying " to keep up with it " . She said she was not aware that Proteus Mirabalis was a fecal bacterium. She was not aware of any recent in-services on incontinent care. Review of the facility's Policy and Procedure for when to change an indwelling urinary catheter was a handout printed off of the internet from HICPAC (Healthcare Infeciton Control Practices Advisory Committe) - Guideline for Prevention of Catheter-Associated Urinary Tract Infections dated 2009 documented ".....changing an indwelling catheters or drainage bags at routine, fixed intervals is not recomended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised....Category II...." Review of "Category II" documented ".....a weak recommendation supported by any quality evidence suggesting a tradeoff between clinical benefits and harms....." This document wsa given as the facility policy and procedure for indwelling urinary catheter changes by RNC #1. RNC #1 stated that the corporation adopted this as their policy and procedure in August 2012 and the facilities had put this suggestion into place at that time. In an interview on 3/25/13 at 1:30 p.m. CNA #2 stated that the last time she had taken care (which was documented on the kiosk as 3/10/13) of Resident #3 she reported to the nurse that the urine was a dark brown color and that she did inform the charge nurse, but was unable to state which nurse she had reported this to. CNA #2 stated that it was the day charge nurse for the west side. Review of the facility ' s Infection Reports revealed two forms being used. One contained the questions " Health Care Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " which had yes or no answers. The second Infection Report Form documented " ....Facility Acquired Infection developed after admission? " and " Community Acquired Evidence of Infection at time of admission? " Both with yes or no answers. Seventeen Infection Reports of residents with UTI ' s were reviewed for whether they were marked to indicate if the UTI was an HAI or CAI. Nine of the reports had both questions marked " No " , seven had neither question answered, and one had HAI question left blank and answered " No " on the CAI question. In an interview on 3/26/13 at 10:50 a.m. with the DON, ADON #2 and RNC #1, RNC #1 stated that there were criteria for determining if a resident infection was a Healthcare Associated Infection (HAI) and ADON #2 pointed to the criteria listed on the HAI form. In an interview on 3/26/13 at 3:50 p.m. and 4:30 p.m. RNC #2 stated that on the Infection Report form the questions " Healthcare Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " should be answered either yes or no. If the HAI question is answered " yes " , then the Healthcare Associated Infection Surveillance Report Form should be filled out. RNC #2 stated that the Infection Control Policy criteria was to determine if there was an infection and the HAI Surveillance Report Form criteria was to help determine if the infection was chronic or acute. In an interview on 3/27/13 at 9:30 a.m. ADON #2 stated that she had no instruction on how to fill out the Infection Control Log. Review of Resident #1 ' s clinical record " Admission Record " undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Observation on 3/22/12 at 9:15 a.m. CNA #7 providing incontinent care to Resident #1 revealed CNA #7 rubbing back and forth with the same piece of cloth on the urinary catheter. CNA #7 then cleaned stool from an incontinent episode of bowel movement from the bottom up, spreading stool to vaginal/peri area. Observation on 3/21/13 at 3:40 p.m. revealed that Resident #1 ' s urinary catheter tubing contained dark amber urine with sediment in the tubing. ADON #2 stated that she thought the urine was yellow, but when questioned, she stated that she would call the urine amber. ADON #2 stated that with the sediment in the tubing and the color of the urine, she thought that Resident #1 might have a urinary tract infection. Review of Resident #1 ' s clinical record " Diagnostics " dated 3/19/13 documented Resident #1 ' s urine contained the bacterium Escherichia coli (which is intestinal bacteria). Review of Resident #2 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]., hypertension and [MEDICAL CONDITION]. Review of Resident #2 ' s clinical record " Diagnostics " dated 1/23/13 document her urine contained Escherichia coli, [MEDICATION NAME] cloacae, and proteus mirabilis which is commonly found in the intestines or fecal material. Review of Resident #7 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #7 ' s clinical record " Diagnostics " dated 2/7/13 documented her urinalysis and culture and sensitivity contained Escherichia Coli which is intestinal bacteria. Review of Resident #8 ' s admission record undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #8 ' s clinical record " Diagnostics " dated 1/12/13 documented her urinalysis and culture and sensitivity contained Proteus mirabilis which is intestinal bacteria. Review of Resident #9 ' s admission record revealed she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9 ' s clinical record " Diagnostics " dated 2/5/13 documented her urinalysis and culture and sensitivity contained [MEDICATION NAME] Faecalis which is intestinal bacteria. Review of Resident #11 ' s admission record revealed he was an [AGE] year old male who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #11 ' s clinical record " Nurse ' s Notes " documented he was admitted to the facility on [DATE] with an indwelling urinary catheter. On the date of admission (3/14/13) at 6:40 p.m. he pulled the catheter out and it was re-inserted by nursing staff. Review of Resident #11 ' s clinical record " Admission Order " revealed no evidence of documentation for an indwelling urinary catheter. Review of Resident #11 ' s clinical record " Physician order [REDACTED]. Review of Resident #12 ' s clinical record " Resident Admission Record " undated documented that she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12 ' s clinical record " Nurse ' s Notes " dated 3/11/13 at 0840 (8:40 a.m.) documented " ... ...hospice notified the time of resident pulling out Foley catheter on previous shift, awaiting new orders(to be) called back from hospice .... " There was no evidence of documentation that hospice had called back or from the physician regarding to discontinue the Foley catheter. Review of Resident #12 ' s clinical record " Re-admission orders [REDACTED]. Review of Resident #12 ' s clinical record " Physician order [REDACTED]. Observation on 3/22/13 at 9:50 a.m. revealed that Resident #12 did not have an indwelling urinary catheter in place. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that she had been told there was an order to discontinue Resident #12 ' s indwelling urinary catheter, but that she had not been able to find one in the clinical record. In an interview on 3/22/13 at 10:55 a.m. ADON #1 stated that she thought an order had been faxed to discontinue the indwelling urinary catheter, but that she didn ' t " know what happened there. " Review of Resident #12 ' s clinical record " Diagnostics " dated 1/4/13 documented Resident #12 ' s urinalysis, culture and sensitivity documented she had Proteus mirabilis and [DIAGNOSES REDACTED] oxytoca in her urine. Proteus mirabilis and [DIAGNOSES REDACTED] oxytoca are commonly found in fecal material (stool). Review of Resident #17 ' s admission record documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #17 ' s clinical record " Diagnostics " dated 2/3/13 documented her urine contained Proteus mirabilis which is commonly found in fecal material (stool). The Administrator, DON, RNC #1 was informed 3/22/13 at 10:45 a.m. that Immediate Jeopardy was declared. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "3/22/13 revised 3/27/13" accepted at 11:00 a.m. documented ".....The Immediate Jeopardy was declared at 10:45 a.m. on 3/22/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education being presented to the facility staff nurses by the Director of Nursing/Unit Managers. - Incontinent Care - Foley Catheter Care - Foley Catheter Assessments and Documentation of color/clarity/characteristics by licensed nurse Re-education was started immediately with current staff in the facility: (copies of education provided is attached). In-service has been provided for licensed nurses for re-education regarding importance of Foley catheter care, documenting after Certified Nursing assistants provides Foley catheter care, and nurse assessment of patency of catheter, color and clarity of urine every shift. As of 3/26/13 at 11:30 a.m. all certified nursing assistants have been re-educated on incontinent care, Foley catheter care and successfully performed incontinent care observed by the Director of Nursing and/or Assistant Directors of Nursing using the skills checklist for incontinent care (sample attached). The exception is three certified nursing assistants wh

Based on observation, interview and record review, the facility failed to ensure three of four Certified Nurse Aides (CNA's) were able to demonstrate competency in skills and techniques necessary to care for resident's needs for two of two resident's (Residents #12 and #16) reviewed for incontinent care. The facility failed to ensure: a. CNA's were able to demonstrate quality and safe incontinent care to residents who require incontinent care services b. Provide recent in-services for providing quality and safe incontinent care This deficient practice could affect any of the 45 residents who were frequently incontinent of bladder and/or the 34 residents who were frequently incontinent of bowel resulting in cross contamination and risk for bacteria into the urinary tract causing infection. The findings included: An Immediate Jeopardy was identified on 3/22/13 at 10:45 a.m. While the Immediate Jeopardy was removed 3/27/13 at 11:00 a.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Forty-five incontinent residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: In an interview on 3/25/13 at 10:20 a.m. ADON #2 stated that the nurse who had been doing infection control left in January 2013 and that she (ADON #2) had been trying " to keep up with it " . She said she was not aware that Proteus Mirabalis was a fecal bacterium. She was not aware of any recent in-services on incontinent care. Review of Resident #3 ' s clinical record " Resident Admission Record " documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/29/11 documented she was admitted to the facility with an indwelling Foley catheter with a wound vac to her coccyx. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 6/8/12 documented her Stage IV pressure ulcer to her coccyx had closed. Review of Resident #3 ' s clinical record there was no evidence of documentation of any calls to her physician or attempts to remove the Foley catheter since wound healing. Review of Resident #3 ' s clinical record " Minimum Data Set (MDS) " dated 2/17/13 documented under Speech Clarity Resident #3 was documented as having no speech - absence of spontaneous speech. Under Cognitive Skills for Daily Decision Making, it was documented as severely impaired - never/rarely made decisions. Under Functional Status, Bed Mobility, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Transfer, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Locomotion on Unit, Dressing, Toilet Use, Personal Hygiene, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Bladder and Bowel, Resident #3 was documented as having an indwelling Foley catheter for urine elimination and Ostomy for bowel movements. Review of Resident #3 ' s clinical record " Care Plan " dated 2/28/13 documented under Problem documented " .....I have a potential for compromised psychosocial well-being due to being a bed bound resident in the facility I reside in .... " Problem documented " ....Due to my health status I stay in my room. I like to listen to music or the TV. I need assistance turning the TV on, or on the radio, occasionally I attend to special events, and also I enjoy my family visits ..... " Problem documented " .....I am bedfast and my cognitive status/decision making skills are impaired ....I require extensive to total assistance with ADL ' s (Activities of Daily Living) .....Under Goal documented " ....I will have my needs anticipated and met by staff for 90 days .... " Review of Resident #3 ' s clinical record " Physician ' s Progress Notes " dated 3/19/13 untimed, documented " .....staff reported patient vomited twice over night ....up in wheelchair ....alert, no fever, no acute distress, will watch ....[MEDICATION NAME] (anti-emetic used for nausea/vomiting) prn (as needed) ... .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/18/13 at 2310 (11:10 p.m.) documented by LVN #7 " .....resident vomited times one, [MEDICATION NAME] as needed 25 mg po (by mouth) given ....HOB (head of bed) elevated ....physician notified ..... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0300 (3:00 a.m.) documented by LVN #7 " ... ...feeding resident, vomited again and physician ' s office notified .....order hold feeding and give [MEDICATION NAME] 25 mg po (per oral or by mouth) .... Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0800 (8:00 a.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....respirations regular and non-labored, lung sounds clear to auscultation in front and back .....abdomen soft and non-distended ... ...bowel sounds in four quadrants ... ...[DEVICE] (an artificial opening on the abdomen that enters the stomach for the purpose of liquid feeding formula) patent and intact .....no signs/symptoms of aspiration noted .....Placement checked, no residual noted ....breakfast feedings held due to patient ate 50% of meal .....family called and notified about resident vomiting last night .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 10:00 a.m. documented by LVN #2 " ... ...resident resting in bed with eyes open, respirations regular and non-labored, lung sounds clear to auscultation in front and back .....[DEVICE] patent and intact ....Foley catheter patent and draining clear yellow urine ....[MEDICAL CONDITION] patent with soft stool in bag .....HOB elevated ...no distress noted at this time ... ... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 12:35 p.m. documented by LVN #2 " ... ...physician here to assess resident .....see progress notes .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 1340 (1:40 p.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....HOB elevated ....Vital Signs (VS) blood pressure 118/54, heart rate 135, respirations 36, temperature 96.5, oxygen saturation 96%...accu-check (a finger stick used to collect blood to measure blood glucose (sugar) levels) 235 .....responding slightly to verbal stimuli ...diaphoretic and [MEDICAL CONDITION] .....lung sounds clear to auscultation, no nausea/vomiting noted ....Foley catheter patent draining clear yellow urine, [DEVICE] patent ....[MEDICAL CONDITION] patent with soft stool present .....send resident to emergency department for evaluation and treatment .....physician and family notified ..... " Record review of the local EMS (emergency medical services) " Run Sheet " dated 3/19/13 beginning at 1418 (2:18 p.m.) and ending at the local emergency department at 1432 (2:42 p.m.), when arrived at the local emergency department, documented " ....staff states patient vomited twice previously .....requesting transport for possible aspiration - patient has history of severe dementia .....tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate) [MEDICAL CONDITION] (low blood pressure) and diaphoresis (sweating) .....patient transferred to EMS cot via three person lift ....IV attempt twice was unsuccessful ....impression - septic shock ..... " Review of the EMS " Run Sheet " dated 3/19/13 at 1418 (2:18 p.m.) the first set of vital signs were documented the blood pressure as 89/53, pulse 134, respirations 20. Observation on 3/21/13 at 9:00 a.m. at the local hospital Intensive Care Unit revealed Resident #3 had a large unstageable pressure sore on her right heel. In an interview on 3/22/13 at 1:10 p.m. the Emergency Department Registered Nurse that received Resident #3 into the emergency department stated that when she received Resident #3 from the emergency medical services, Resident #3 was not alert, her rectal temperature was elevated and her Foley catheter was draining thick gray pus. She stated that Resident #3 was in a very bad state, diaphoretic (soaked in sweat) and had a general bad odor about her. She stated that Resident #3 was very dirty when she arrived to the emergency room . In an interview on 3/21/13 at 8:15 a.m. Intensive Care Unit (ICU) nurse (ICU nurse #1) that had care for Resident #3 when she was first admitted to the ICU stated that when she received Resident #3 from the emergency room , that Resident #3 was filthy and her Foley catheter had sludge in the tubing clotting off the urine from going into the drainage collection bag. She described the urine as cloudy, nasty green/gray in color and when she removed the Foley that she came to the hospital with from the facility, the tubing was stained and dirty. ICU nurse #1 described that when she removed the old Foley, there were three ICU nurses in the room assisting and two of the ICU nurse ' s had to leave the room vomiting from the overwhelming odor of the urine that saturated the bedding of Resident #3. She stated that after placing a new Foley catheter in Resident #3 and after Resident #3 urinated and soaked the entire bed, Resident #3 voided almost 500 cc (cubic centimeters) of cloudy, dark, thick urine. She stated that Resident #3 had dried stool on her buttocks and abdomen. She stated that she had given Resident #3 two head to toe bed baths during her shift and Resident #3 still was not clean when she turned over care to the oncoming nurse. In an interview on 3/25/13 at 10:50 a.m. Intensive Care Unit (ICU) nurse #2 that took over care of Resident #3 stated that she also gave Resident #3 two complete head to toe bed baths and finally got her cleaned up. She stated that she had called the facility asking when Resident #3 ' s Foley catheter was last changed and the DON told her that it was 2/25/13. The ICU nurse stated that she also informed the DON at the facility that when Resident #3 arrived, she was filthy and her urine was thick, gray sludge and wanted to know how Resident #3 had been cared for. In an interview on 3/21/13 at 8:30 a.m. Resident #3 ' s four daughters were present and stated that the first time they heard of their mother being admitted to the intensive care unit (ICU) was 3/19/13 at night (they were not sure at what time, but it was late evening) when the ICU nurse called them to come see their mother, that she was in critical condition and was not expected to survive. The daughters stated that they had called the facility and spoken with the Administrator and DON about their care concerns for Resident #3. The daughters stated that they had placed a sign above their mother ' s bed with times to be up in the Geri-chair and when to be placed back in bed. They stated that often times their mother would be in the same clothes for several days at a time, that her eyes were frequently matted and the CNA ' s would often leave her dirty frequently. They also stated that there was one CNA that manually picked their mother up from the Geri-chair by herself and placed their mother onto the bed. They stated that their mother was to be transferred by the Hoyer lift only and with two person assist. Review of the local hospital ' s medical records for Resident #3 documented by the first ICU nurse on 3/19/13 at 2100 (9:00 p.m.) documented " ... ....Patient Diagnosis: [REDACTED]..catheter removed and replaced on admission ....Patient voided a large amount of urine incontinently immediately after catheter was removed ... ...urine foul smelling, dark, cloudy and concentrated ....New Foley catheter inserted ..... " Review of the local hospitals medical records for Resident #3 documented by the first ICU nurse on 3/21/13 at 8:00 a.m. " ... ....I received the patient 3/19/13 and her Foley catheter appeared extremely dirty ....urine was very cloudy, a grey-amber color and had an overwhelmingly foul odor ....There was minimal urine output in the bag and urine was stationary in the tubing .....Upon taking out the Foley catheter, patient voided a great amount of urine described above ...after inserting the new catheter, patient immediately had out 450cc of urine described above ....patient was very unclean .... " Review of the hospital ' s " Patient Results " dated 3/19/13 at 1531 (3:51 p.m.) documented the culture and sensitivity (C&S) results as Proteus Mirabilis and Escherichia Coli (both are bacteria commonly found in feces {stool}). Observation on 3/21/13 at 7:50 a.m. at the local hospital Intensive Care Unit (ICU) revealed that Resident #3 had an Indwelling Foley Catheter draining thick, dark amber urine. The ICU nurse caring for Resident #3 stated that the urine looked " so much better " than when she first received her. At this time, Resident #3 was being transferred to another unit at the hospital. Observation on 3/21/13 at 8:45 a.m. at the local hospital in a regular hospital room revealed Resident #3 had an unstageable pressure ulcer located on her right heel that the facility had no evidence of documentation. Also she had two stage II pressure ulcers on the lateral aspect of her right foot. In an interview on 3/22/13 at 10:10 a.m. LVN #3 stated that she had changed the indwelling urinary catheter on Resident #3 on 2/25/13 when she was still working nights. She stated that the nurse working on the west side stated she did not know how to change an indwelling urinary catheter on a resident that was contracted. LVN #3 stated that the old urinary catheter had sediment in the tubing clogging off the flow of urine into the collection bag. LVN #3 stated that when she placed the new indwelling urinary catheter it immediately began draining without any difficulties. LVN #3 stated that she did not detect any odor about Resident #3 or the urine when she changed the catheter on 2/25/13. LVN #3 stated that she did not notify the physician due to the amount of sediment in the catheter tubing. LVN #3 stated that in her professional opinion indwelling urinary catheters should be changed at least once a month or more often if needed. LVN #3 stated in her professional opinion that it would take a very long time for urine to go from clear yellow to thick gray sludge, she was unable to give an estimate on how long it would take. In an interview on 3/21/13 at 11:30 a.m. ADON #2 accompanied this investigator to see the residents that was on the CMS Form 672 dated 3/21/13 that documented the facility having four residents in the facility as having a Foley catheter. Observation at this time revealed only one other resident (Resident #1) as having an indwelling urinary catheter. Resident #12 had not had a Foley catheter " ....for the past three weeks, she pulled her catheter out and hospice said to leave it out .... " There was no evidence of documentation of a physician order [REDACTED]. Resident #6 had not had a catheter since before 10/5/13 when hospice performed an in and out catherization to obtain urine for a urinalysis and culture and sensitivity for a suspected urinary tract infection. ADON #2 stated sarcastically " ....evidently I really know my residents ..... " There was no evidence of documentation of an order to take or leave the catheter out. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that in her professional opinion Foley catheters should be changed monthly. She also stated that some nurse aides measure the urine and document it and some aides only document urine amounts as small, medium or large. In an interview on 3/22/13 at 10:45 a.m. ADON #2 stated that the assessment completed on Resident #3 was a wrong assessment because the nurse did not do a head to toe assessment and the documentation on the assessment documented Resident #3 ' s urine as clear yellow urine. She stated that LVN#2 did not do a complete assessment of Resident #3 due to the fact that LVN #2 had not documented in Resident #3 ' s clinical record regarding the color and clarity of Resident #3 ' s urine until 3/19/13. In an interview on 3/25/13 at 11:39 a.m. CNA #3 stated that she had emptied Resident #3 ' s drainage bag on 3/19/13 before she went off shift at 6:00 a.m. and at that time the urine in the drainage bag was yellow and had bacteria in it. She explained that by having bacteria in the urine she meant that the urine was white and cloudy and to her it looked like this white cloudy stuff was clogging the tubing. She stated that she reported it to the day nurse who was LVN #2. In an interview on 3/22/13 at 11:00 a.m. LVN #2 stated that Resident #3 had vomited twice the night before (3/18/13) she was sent to the hospital. He stated that Resident #3 ate breakfast in bed but did not eat any lunch. The physician saw her and said she was fine. A few hours later (approximately 55 minutes) she started sweating a lot and her pulse rate got fast. LVN #2 stated that Resident #3 was mumbling and not doing the stuff she normally does. After lunch she was not responding, was breathing fast and was sweaty. LVN #2 described Resident #3 ' s urine as being yellow, clear and draining, but he was unable to state how much he observed in the bag at the time of the transfer. In an interview on 3/22/13 at 11:10 a.m. LVN #1 stated that if a resident with a urinary catheter had appeared to have a urinary tract infection it would be best to go ahead and change the catheter, even if waiting on a urinalysis. In an interview on 3/22/13 at 11:15 a.m. LVN #1 stated there were no open areas on Resident #3 ' s feet and that he had assess her skin the morning prior to her being sent to the emergency department and that he did not look at her urine. In an interview on 3/22/13 at 12:20 p.m. the Medical Director for the facility stated that he was unaware that the facility had changed their policy of changing indwelling urinary catheters monthly to as needed. He stated that in his professional medical opinion, urinary catheters needed to be changed at least once a month or sooner if needed. He stated that " .....I just don ' t know what to do with that facility .... " In an interview on 3/22/13 at 3:05 p.m. the DON stated that she tracks bowel movements, oral and [DEVICE] administered intakes. She stated that she does not see anything on outputs (such as urine). She stated that the system goes down every day at 2:00 a.m. and 2:00 p.m. but it does not stay down for very long (she was unable to give an estimated amount of time the system would be down). She stated that she had been training staff on fluid intake. In an interview on 3/22/13 at 3:15 p.m. CNA #5 stated that when she worked with Resident #3 on 3/18/13 the urine was dark yellow and she did not think anything of it because since her employment began in August 2012, Resident #3 ' s urine had always been dark yellow with " stuff " in the tubing. CNA #5 stated that the reason she did not tell any of the charge nurses about the color and clarity of Resident #3 ' s urine was because the urine hadn ' t changed since she had begun working in August, 2012. In an interview on 3/22/13 at 3:25 p.m. CNA #6 stated that she would go and ask the nurse how to input color, consistency and amount of urine into the kiosk. She stated that it was very important to keep the catheter clean and to be very careful while completing peri-care because it they didn ' t want to give the residents who have indwelling urinary catheters an infection. In an interview on 3/24/13 at 8:20 a.m. RN #1 stated that she worked weekends, but had been off and had not worked with Resident #3 for over a month. During the interview she said that in her professional opinion indwelling urinary catheters should be change done a month or sooner if needed. RN #1 was no aware of any facility criteria for changing out urinary catheters. In an interview on 3/25/13 at 1:30 p.m. CNA #2 stated that the last time she had taken care (which was documented on the kiosk as 3/10/13) of Resident #3 she reported to the nurse that the urine was a dark brown color and that she did inform the charge nurse, but was unable to state which nurse she had reported this to. CNA #2 stated that it was the day charge nurse for the west side. Review of the facility ' s Infection Reports revealed two forms being used. One contained the questions " Health Care Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " which had yes or no answers. The second Infection Report Form documented " ....Facility Acquired Infection developed after admission? " and " Community Acquired Evidence of Infection at time of admission? " Both with yes or no answers. Seventeen Infection Reports of residents with UTI ' s were reviewed for whether they were marked to indicate if the UTI was an HAI or CAI. Nine of the reports had both questions marked " No " , seven had neither question answered, and one had HAI question left blank and answered " No " on the CAI question. In an interview on 3/26/13 at 10:50 a.m. with the DON, ADON #2 and RNC #1, RNC #1 stated that there were criteria for determining if a resident infection was a Healthcare Associated Infection (HAI) and ADON #2 pointed to the criteria listed on the HAI form. In an interview on 3/26/13 at 3:50 p.m. and 4:30 p.m. RNC #2 stated that on the Infection Report form the questions " Healthcare Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " should be answered either yes or no. If the HAI question is answered " yes " , then the Healthcare Associated Infection Surveillance Report Form should be filled out. RNC #2 stated that the Infection Control Policy criteria was to determine if there was an infection and the HAI Surveillance Report Form criteria was to help determine if the infection was chronic or acute. In an interview on 3/27/13 at 9:30 a.m. ADON #2 stated that she had no instruction on how to fill out the Infection Control Log. Review of Resident #1 ' s clinical record " Admission Record " undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Observation on 3/22/12 at 9:15 a.m. CNA #7 providing incontinent care to Resident #1 revealed CNA #7 rubbing back and forth with the same piece of cloth on the urinary catheter. CNA #7 then cleaned stool from an incontinent episode of bowel movement from the bottom up, spreading stool to vaginal/peri area. Observation on 3/21/13 at 3:40 p.m. revealed that Resident #1 ' s urinary catheter tubing contained dark amber urine with sediment in the tubing. ADON #2 stated that she thought the urine was yellow, but when questioned, she stated that she would call the urine amber. ADON #2 stated that with the sediment in the tubing and the color of the urine, she thought that Resident #1 might have a urinary tract infection. Review of Resident #1 ' s clinical record " Diagnostics " dated 3/19/13 documented Resident #1 ' s urine contained the bacterium Escherichia coli (which is intestinal bacteria). Review of Resident #2 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]., hypertension and [MEDICAL CONDITION]. Review of Resident #2 ' s clinical record " Diagnostics " dated 1/23/13 document her urine contained Escherichia coli, [MEDICATION NAME] cloacae, and proteus mirabilis which is commonly found in the intestines or fecal material. Review of Resident #7 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #7 ' s clinical record " Diagnostics " dated 2/7/13 documented her urinalysis and culture and sensitivity contained Escherichia Coli which is intestinal bacteria. Review of Resident #8 ' s admission record undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #8 ' s clinical record " Diagnostics " dated 1/12/13 documented her urinalysis and culture and sensitivity contained Proteus mirabilis which is intestinal bacteria. Review of Resident #9 ' s admission record revealed she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9 ' s clinical record " Diagnostics " dated 2/5/13 documented her urinalysis and culture and sensitivity contained [MEDICATION NAME] Faecalis which is intestinal bacteria. Review of Resident #11 ' s admission record revealed he was an [AGE] year old male who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #11 ' s clinical record " Nurse ' s Notes " documented he was admitted to the facility on [DATE] with an indwelling urinary catheter. On the date of admission (3/14/13) at 6:40 p.m. he pulled the catheter out and it was re-inserted by nursing staff. Review of Resident #11 ' s clinical record " Admission Order " revealed no evidence of documentation for an indwelling urinary catheter. Review of Resident #11 ' s clinical record " Physician order [REDACTED]. Review of Resident #12 ' s clinical record " Resident Admission Record " undated documented that she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12 ' s clinical record " Nurse ' s Notes " dated 3/11/13 at 0840 (8:40 a.m.) documented " ... ...hospice notified the time of resident pulling out Foley catheter on previous shift, awaiting new orders(to be) called back from hospice .... " There was no evidence of documentation that hospice had called back or from the physician regarding to discontinue the Foley catheter. Review of Resident #12 ' s clinical record " Re-admission orders [REDACTED]. Review of Resident #12 ' s clinical record " Physician order [REDACTED]. Observation on 3/22/13 at 9:50 a.m. revealed that Resident #12 did not have an indwelling urinary catheter in place. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that she had been told there was an order to discontinue Resident #12 ' s indwelling urinary catheter, but that she had not been able to find one in the clinical record. In an interview on 3/22/13 at 10:55 a.m. ADON #1 stated that she thought an order had been faxed to discontinue the indwelling urinary catheter, but that she didn ' t " know what happened there. " Review of Resident #12 ' s clinical record " Diagnostics " dated 1/4/13 documented Resident #12 ' s urinalysis, culture and sensitivity documented she had Proteus mirabilis and [DIAGNOSES REDACTED] oxytoca in her urine. Proteus mirabilis and [DIAGNOSES REDACTED] oxytoca are commonly found in fecal material (stool). Review of Resident #17 ' s admission record documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #17 ' s clinical record " Diagnostics " dated 2/3/13 documented her urine contained Proteus mirabilis which is commonly found in fecal material (stool). The Administrator, DON, RNC #1 was informed 3/22/13 at 10:45 a.m. that Immediate Jeopardy was declared. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "3/22/13 revised 3/27/13" accepted at 11:00 a.m. documented ".....The Immediate Jeopardy was declared at 10:45 a.m. on 3/22/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education being presented to the facility staff nurses by the Director of Nursing/Unit Managers. - Incontinent Care - Foley Catheter Care - Foley Catheter Assessments and Documentation of color/clarity/characteristics by licensed nurse Re-education was started immediately with current staff in the facility: (copies of education provided is attached). In-service has been provided for licensed nurses for re-education regarding importance of Foley catheter care, documenting after Certified Nursing assistants provides Foley catheter care, and nurse assessment of patency of catheter, color and clarity of urine every shift. As of 3/26/13 at 11:30 a.m. all certified nursing assistants have been re-educated on incontinent care, Foley catheter care and successfully performed incontinent care observed by the Director of Nursing and/or Assistant Directors of Nursing using the skills checklist for incontinent care (sample attached). The exception is three certified nursing assistants who are prn (as needed) and are not scheduled. These three identified certified nursing assistants will not be allowed to work until they have been re-educated and successfully completed incontinent care using the skills checklist for incontinent care. All licensed charge nurses have been re-educated on Foley catheters and incontinent care including documentation. The exception is one PRN (as needed) licensed nurses who is not scheduled to work and will not be allowed to work until the re-education is completed. System Changes: There are no residents with Foley catheters in the facility as of 3/25/13 at 7:00 p.m. Future orders for Foley catheters will read: Change indwelling Foley catheters as needed prn dysfunction. Certified Nursing Assistants are required to not only document urine

Based on observations, interviews and record reviews the facility failed to notify the legal representative regarding a significant change in the physical/clinical status for one of 17 residents (Resident #3) reviewed for care. http://www.hgexperts.com/article.asp?id=6237 from the Texas Board of Nursing documents "....A standard of care holds a person of exceptional skill or knowledge to a duty of acting as would a reasonable and prudent person possessing the same or similar skills or knowledge under the same or similar circumstances. Standards of care may serve as guidelines when evaluating nursing care for possible negligence. They define acts that are permitted to be performed or prohibited from being performed. SOC ' s give direction to the nurse ? defining what should or should not be done for patients....." An Immediate Jeopardy was identified on 3/22/13 at 10:45 a.m. While the Immediate Jeopardy was removed 3/27/13 at 11:00 a.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Seventy-one residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #3 ' s clinical record " Resident Admission Record " documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/29/11 documented she was admitted to the facility with an indwelling Foley catheter with a wound vac to her coccyx. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 6/8/12 documented her Stage IV pressure ulcer to her coccyx had closed. Review of Resident #3 ' s clinical record there was no evidence of documentation of any calls to her physician or attempts to remove the Foley catheter since wound healing. Review of Resident #3 ' s clinical record " Minimum Data Set (MDS) " dated 2/17/13 documented under Speech Clarity Resident #3 was documented as having no speech - absence of spontaneous speech. Under Cognitive Skills for Daily Decision Making, it was documented as severely impaired - never/rarely made decisions. Under Functional Status, Bed Mobility, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Transfer, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Locomotion on Unit, Dressing, Toilet Use, Personal Hygiene, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Bladder and Bowel, Resident #3 was documented as having an indwelling Foley catheter for urine elimination and Ostomy for bowel movements. Review of Resident #3 ' s clinical record " Care Plan " dated 2/28/13 documented under Problem documented " .....I have a potential for compromised psychosocial well-being due to being a bed bound resident in the facility I reside in .... " Problem documented " ....Due to my health status I stay in my room. I like to listen to music or the TV. I need assistance turning the TV on, or on the radio, occasionally I attend to special events, and also I enjoy my family visits ..... " Problem documented " .....I am bedfast and my cognitive status/decision making skills are impaired ....I require extensive to total assistance with ADL ' s (Activities of Daily Living) .....Under Goal documented " ....I will have my needs anticipated and met by staff for 90 days .... " Review of Resident #3 ' s clinical record " Physician ' s Progress Notes " dated 3/19/13 untimed, documented " .....staff reported patient vomited twice over night ....up in wheelchair ....alert, no fever, no acute distress, will watch ....[MEDICATION NAME] (anti-emetic used for nausea/vomiting) prn (as needed) ... .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/18/13 at 2310 (11:10 p.m.) documented by LVN #7 " .....resident vomited times one, [MEDICATION NAME] as needed 25 mg po (by mouth) given ....HOB (head of bed) elevated ....physician notified ..... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0300 (3:00 a.m.) documented by LVN #7 " ... ...feeding resident, vomited again and physician ' s office notified .....order hold feeding and give [MEDICATION NAME] 25 mg po (per oral or by mouth) .... Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0800 (8:00 a.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....respirations regular and non-labored, lung sounds clear to auscultation in front and back .....abdomen soft and non-distended ... ...bowel sounds in four quadrants ... ...[DEVICE] (an artificial opening on the abdomen that enters the stomach for the purpose of liquid feeding formula) patent and intact .....no signs/symptoms of aspiration noted .....Placement checked, no residual noted ....breakfast feedings held due to patient ate 50% of meal .....family called and notified about resident vomiting last night .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 10:00 a.m. documented by LVN #2 " ... ...resident resting in bed with eyes open, respirations regular and non-labored, lung sounds clear to auscultation in front and back .....[DEVICE] patent and intact ....Foley catheter patent and draining clear yellow urine ....[MEDICAL CONDITION] patent with soft stool in bag .....HOB elevated ...no distress noted at this time ... ... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 12:35 p.m. documented by LVN #2 " ... ...physician here to assess resident .....see progress notes .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 1340 (1:40 p.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....HOB elevated ....Vital Signs (VS) blood pressure 118/54, heart rate 135, respirations 36, temperature 96.5, oxygen saturation 96%...accu-check (a finger stick used to collect blood to measure blood glucose (sugar) levels) 235 .....responding slightly to verbal stimuli ...diaphoretic and [MEDICAL CONDITION] .....lung sounds clear to auscultation, no nausea/vomiting noted ....Foley catheter patent draining clear yellow urine, [DEVICE] patent ....[MEDICAL CONDITION] patent with soft stool present .....send resident to emergency department for evaluation and treatment .....physician and family notified ..... " Record review of the local EMS (emergency medical services) " Run Sheet " dated 3/19/13 beginning at 1418 (2:18 p.m.) and ending at the local emergency department at 1432 (2:42 p.m.), when arrived at the local emergency department, documented " ....staff states patient vomited twice previously .....requesting transport for possible aspiration - patient has history of severe dementia .....tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate) [MEDICAL CONDITION] (low blood pressure) and diaphoresis (sweating) .....patient transferred to EMS cot via three person lift ....IV attempt twice was unsuccessful ....impression - septic shock ..... " Review of the EMS " Run Sheet " dated 3/19/13 at 1418 (2:18 p.m.) the first set of vital signs were documented the blood pressure as 89/53, pulse 134, respirations 20. Observation on 3/21/13 at 9:00 a.m. at the local hospital Intensive Care Unit revealed Resident #3 had a large unstageable pressure sore on her right heel. In an interview on 3/22/13 at 1:10 p.m. the Emergency Department Registered Nurse that received Resident #3 into the emergency department stated that when she received Resident #3 from the emergency medical services, Resident #3 was not alert, her rectal temperature was elevated and her Foley catheter was draining thick gray pus. She stated that Resident #3 was in a very bad state, diaphoretic (soaked in sweat) and had a general bad odor about her. She stated that Resident #3 was very dirty when she arrived to the emergency room . In an interview on 3/21/13 at 8:15 a.m. Intensive Care Unit (ICU) nurse (ICU nurse #1) that had care for Resident #3 when she was first admitted to the ICU stated that when she received Resident #3 from the emergency room , that Resident #3 was filthy and her Foley catheter had sludge in the tubing clotting off the urine from going into the drainage collection bag. She described the urine as cloudy, nasty green/gray in color and when she removed the Foley that she came to the hospital with from the facility, the tubing was stained and dirty. ICU nurse #1 described that when she removed the old Foley, there were three ICU nurses in the room assisting and two of the ICU nurse ' s had to leave the room vomiting from the overwhelming odor of the urine that saturated the bedding of Resident #3. She stated that after placing a new Foley catheter in Resident #3 and after Resident #3 urinated and soaked the entire bed, Resident #3 voided almost 500 cc (cubic centimeters) of cloudy, dark, thick urine. She stated that Resident #3 had dried stool on her buttocks and abdomen. She stated that she had given Resident #3 two head to toe bed baths during her shift and Resident #3 still was not clean when she turned over care to the oncoming nurse. In an interview on 3/25/13 at 10:50 a.m. Intensive Care Unit (ICU) nurse #2 that took over care of Resident #3 stated that she also gave Resident #3 two complete head to toe bed baths and finally got her cleaned up. She stated that she had called the facility asking when Resident #3 ' s Foley catheter was last changed and the DON told her that it was 2/25/13. The ICU nurse stated that she also informed the DON at the facility that when Resident #3 arrived, she was filthy and her urine was thick, gray sludge and wanted to know how Resident #3 had been cared for. In an interview on 3/21/13 at 8:30 a.m. Resident #3 ' s four daughters were present and stated that the first time they heard of their mother being admitted to the intensive care unit (ICU) was 3/19/13 at night (they were not sure at what time, but it was late evening) when the ICU nurse called them to come see their mother, that she was in critical condition and was not expected to survive. The daughters stated that they had called the facility and spoken with the Administrator and DON about their care concerns for Resident #3. The daughters stated that they had placed a sign above their mother ' s bed with times to be up in the Geri-chair and when to be placed back in bed. They stated that often times their mother would be in the same clothes for several days at a time, that her eyes were frequently matted and the CNA ' s would often leave her dirty frequently. They also stated that there was one CNA that manually picked their mother up from the Geri-chair by herself and placed their mother onto the bed. They stated that their mother was to be transferred by the Hoyer lift only and with two person assist. Review of the local hospital ' s medical records for Resident #3 documented by the first ICU nurse on 3/19/13 at 2100 (9:00 p.m.) documented " ... ....Patient Diagnosis: [REDACTED]..catheter removed and replaced on admission ....Patient voided a large amount of urine incontinently immediately after catheter was removed ... ...urine foul smelling, dark, cloudy and concentrated ....New Foley catheter inserted ..... " Review of the local hospitals medical records for Resident #3 documented by the first ICU nurse on 3/21/13 at 8:00 a.m. " ... ....I received the patient 3/19/13 and her Foley catheter appeared extremely dirty ....urine was very cloudy, a grey-amber color and had an overwhelmingly foul odor ....There was minimal urine output in the bag and urine was stationary in the tubing .....Upon taking out the Foley catheter, patient voided a great amount of urine described above ...after inserting the new catheter, patient immediately had out 450cc of urine described above ....patient was very unclean .... " Review of the hospital ' s " Patient Results " dated 3/19/13 at 1531 (3:51 p.m.) documented the culture and sensitivity (C&S) results as Proteus Mirabilis and Escherichia Coli (both are bacteria commonly found in feces {stool}). Observation on 3/21/13 at 7:50 a.m. at the local hospital Intensive Care Unit (ICU) revealed that Resident #3 had an Indwelling Foley Catheter draining thick, dark amber urine. The ICU nurse caring for Resident #3 stated that the urine looked " so much better " than when she first received her. At this time, Resident #3 was being transferred to another unit at the hospital. Observation on 3/21/13 at 8:45 a.m. at the local hospital in a regular hospital room revealed Resident #3 had an unstageable pressure ulcer located on her right heel that the facility had no evidence of documentation. Also she had two stage II pressure ulcers on the lateral aspect of her right foot. In an interview on 3/22/13 at 10:10 a.m. LVN #3 stated that she had changed the indwelling urinary catheter on Resident #3 on 2/25/13 when she was still working nights. She stated that the nurse working on the west side stated she did not know how to change an indwelling urinary catheter on a resident that was contracted. LVN #3 stated that the old urinary catheter had sediment in the tubing clogging off the flow of urine into the collection bag. LVN #3 stated that when she placed the new indwelling urinary catheter it immediately began draining without any difficulties. LVN #3 stated that she did not detect any odor about Resident #3 or the urine when she changed the catheter on 2/25/13. LVN #3 stated that she did not notify the physician due to the amount of sediment in the catheter tubing. LVN #3 stated that in her professional opinion indwelling urinary catheters should be changed at least once a month or more often if needed. LVN #3 stated in her professional opinion that it would take a very long time for urine to go from clear yellow to thick gray sludge, she was unable to give an estimate on how long it would take. In an interview on 3/21/13 at 11:30 a.m. ADON #2 accompanied this investigator to see the residents that was on the CMS Form 672 dated 3/21/13 that documented the facility having four residents in the facility as having a Foley catheter. Observation at this time revealed only one other resident (Resident #1) as having an indwelling urinary catheter. Resident #12 had not had a Foley catheter " ....for the past three weeks, she pulled her catheter out and hospice said to leave it out .... " There was no evidence of documentation of a physician order [REDACTED]. Resident #6 had not had a catheter since before 10/5/13 when hospice performed an in and out catherization to obtain urine for a urinalysis and culture and sensitivity for a suspected urinary tract infection. ADON #2 stated sarcastically " ....evidently I really know my residents ..... " There was no evidence of documentation of an order to take or leave the catheter out. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that in her professional opinion Foley catheters should be changed monthly. She also stated that some nurse aides measure the urine and document it and some aides only document urine amounts as small, medium or large. In an interview on 3/22/13 at 10:45 a.m. ADON #2 stated that the assessment completed on Resident #3 was a wrong assessment because the nurse did not do a head to toe assessment and the documentation on the assessment documented Resident #3 ' s urine as clear yellow urine. She stated that LVN#2 did not do a complete assessment of Resident #3 due to the fact that LVN #2 had not documented in Resident #3 ' s clinical record regarding the color and clarity of Resident #3 ' s urine until 3/19/13. In an interview on 3/25/13 at 11:39 a.m. CNA #3 stated that she had emptied Resident #3 ' s drainage bag on 3/19/13 before she went off shift at 6:00 a.m. and at that time the urine in the drainage bag was yellow and had bacteria in it. She explained that by having bacteria in the urine she meant that the urine was white and cloudy and to her it looked like this white cloudy stuff was clogging the tubing. She stated that she reported it to the day nurse who was LVN #2. In an interview on 3/22/13 at 11:00 a.m. LVN #2 stated that Resident #3 had vomited twice the night before (3/18/13) she was sent to the hospital. He stated that Resident #3 ate breakfast in bed but did not eat any lunch. The physician saw her and said she was fine. A few hours later (approximately 55 minutes) she started sweating a lot and her pulse rate got fast. LVN #2 stated that Resident #3 was mumbling and not doing the stuff she normally does. After lunch she was not responding, was breathing fast and was sweaty. LVN #2 described Resident #3 ' s urine as being yellow, clear and draining, but he was unable to state how much he observed in the bag at the time of the transfer. In an interview on 3/22/13 at 11:10 a.m. LVN #1 stated that if a resident with a urinary catheter had appeared to have a urinary tract infection it would be best to go ahead and change the catheter, even if waiting on a urinalysis. In an interview on 3/22/13 at 11:15 a.m. LVN #1 stated there were no open areas on Resident #3 ' s feet and that he had assess her skin the morning prior to her being sent to the emergency department and that he did not look at her urine. In an interview on 3/22/13 at 12:20 p.m. the Medical Director for the facility stated that he was unaware that the facility had changed their policy of changing indwelling urinary catheters monthly to as needed. He stated that in his professional medical opinion, urinary catheters needed to be changed at least once a month or sooner if needed. He stated that " .....I just don ' t know what to do with that facility .... " In an interview on 3/22/13 at 3:05 p.m. the DON stated that she tracks bowel movements, oral and [DEVICE] administered intakes. She stated that she does not see anything on outputs (such as urine). She stated that the system goes down every day at 2:00 a.m. and 2:00 p.m. but it does not stay down for very long (she was unable to give an estimated amount of time the system would be down). She stated that she had been training staff on fluid intake. In an interview on 3/22/13 at 3:15 p.m. CNA #5 stated that when she worked with Resident #3 on 3/18/13 the urine was dark yellow and she did not think anything of it because since her employment began in August 2012, Resident #3 ' s urine had always been dark yellow with " stuff " in the tubing. CNA #5 stated that the reason she did not tell any of the charge nurses about the color and clarity of Resident #3 ' s urine was because the urine hadn ' t changed since she had begun working in August, 2012. In an interview on 3/22/13 at 3:25 p.m. CNA #6 stated that she would go and ask the nurse how to input color, consistency and amount of urine into the kiosk. She stated that it was very important to keep the catheter clean and to be very careful while completing peri-care because it they didn ' t want to give the residents who have indwelling urinary catheters an infection. In an interview on 3/24/13 at 8:20 a.m. RN #1 stated that she worked weekends, but had been off and had not worked with Resident #3 for over a month. During the interview she said that in her professional opinion indwelling urinary catheters should be change done a month or sooner if needed. RN #1 was no aware of any facility criteria for changing out urinary catheters. In an interview on 3/25/13 at 10:20 a.m. ADON #2 stated that the nurse who had been doing infection control left in January 2013 and that she (ADON #2) had been trying " to keep up with it " . She said she was not aware that Proteus Mirabalis was a fecal bacterium. She was not aware of any recent in-services on incontinent care. In an interview on 3/25/13 at 1:30 p.m. CNA #2 stated that the last time she had taken care (which was documented on the kiosk as 3/10/13) of Resident #3 she reported to the nurse that the urine was a dark brown color and that she did inform the charge nurse, but was unable to state which nurse she had reported this to. CNA #2 stated that it was the day charge nurse for the west side. Review of the facility ' s Infection Reports revealed two forms being used. One contained the questions " Health Care Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " which had yes or no answers. The second Infection Report Form documented " ....Facility Acquired Infection developed after admission? " and " Community Acquired Evidence of Infection at time of admission? " Both with yes or no answers. Seventeen Infection Reports of residents with UTI ' s were reviewed for whether they were marked to indicate if the UTI was an HAI or CAI. Nine of the reports had both questions marked " No " , seven had neither question answered, and one had HAI question left blank and answered " No " on the CAI question. In an interview on 3/26/13 at 10:50 a.m. with the DON, ADON #2 and RNC #1, RNC #1 stated that there were criteria for determining if a resident infection was a Healthcare Associated Infection (HAI) and ADON #2 pointed to the criteria listed on the HAI form. In an interview on 3/26/13 at 3:50 p.m. and 4:30 p.m. RNC #2 stated that on the Infection Report form the questions " Healthcare Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " should be answered either yes or no. If the HAI question is answered " yes " , then the Healthcare Associated Infection Surveillance Report Form should be filled out. RNC #2 stated that the Infection Control Policy criteria was to determine if there was an infection and the HAI Surveillance Report Form criteria was to help determine if the infection was chronic or acute. In an interview on 3/27/13 at 9:30 a.m. ADON #2 stated that she had no instruction on how to fill out the Infection Control Log. Review of Resident #1 ' s clinical record " Admission Record " undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Observation on 3/22/12 at 9:15 a.m. CNA #7 providing incontinent care to Resident #1 revealed CNA #7 rubbing back and forth with the same piece of cloth on the urinary catheter. CNA #7 then cleaned stool from an incontinent episode of bowel movement from the bottom up, spreading stool to vaginal/peri area. Observation on 3/21/13 at 3:40 p.m. revealed that Resident #1 ' s urinary catheter tubing contained dark amber urine with sediment in the tubing. ADON #2 stated that she thought the urine was yellow, but when questioned, she stated that she would call the urine amber. ADON #2 stated that with the sediment in the tubing and the color of the urine, she thought that Resident #1 might have a urinary tract infection. Review of Resident #1 ' s clinical record " Diagnostics " dated 3/19/13 documented Resident #1 ' s urine contained the bacterium Escherichia coli (which is intestinal bacteria). Review of Resident #2 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]., hypertension and [MEDICAL CONDITION]. Review of Resident #2 ' s clinical record " Diagnostics " dated 1/23/13 document her urine contained Escherichia coli, [MEDICATION NAME] cloacae, and proteus mirabilis which is commonly found in the intestines or fecal material. Review of Resident #7 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #7 ' s clinical record " Diagnostics " dated 2/7/13 documented her urinalysis and culture and sensitivity contained Escherichia Coli which is intestinal bacteria. Review of Resident #8 ' s admission record undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #8 ' s clinical record " Diagnostics " dated 1/12/13 documented her urinalysis and culture and sensitivity contained Proteus mirabilis which is intestinal bacteria. Review of Resident #9 ' s admission record revealed she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9 ' s clinical record " Diagnostics " dated 2/5/13 documented her urinalysis and culture and sensitivity contained [MEDICATION NAME] Faecalis which is intestinal bacteria. Review of Resident #11 ' s admission record revealed he was an [AGE] year old male who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #11 ' s clinical record " Nurse ' s Notes " documented he was admitted to the facility on [DATE] with an indwelling urinary catheter. On the date of admission (3/14/13) at 6:40 p.m. he pulled the catheter out and it was re-inserted by nursing staff. Review of Resident #11 ' s clinical record " Admission Order " revealed no evidence of documentation for an indwelling urinary catheter. Review of Resident #11 ' s clinical record " Physician order [REDACTED]. Review of Resident #12 ' s clinical record " Resident Admission Record " undated documented that she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12 ' s clinical record " Nurse ' s Notes " dated 3/11/13 at 0840 (8:40 a.m.) documented " ... ...hospice notified the time of resident pulling out Foley catheter on previous shift, awaiting new orders(to be) called back from hospice .... " There was no evidence of documentation that hospice had called back or from the physician regarding to discontinue the Foley catheter. Review of Resident #12 ' s clinical record " Re-admission orders [REDACTED]. Review of Resident #12 ' s clinical record " Physician order [REDACTED]. Observation on 3/22/13 at 9:50 a.m. revealed that Resident #12 did not have an indwelling urinary catheter in place. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that she had been told there was an order to discontinue Resident #12 ' s indwelling urinary catheter, but that she had not been able to find one in the clinical record. In an interview on 3/22/13 at 10:55 a.m. ADON #1 stated that she thought an order had been faxed to discontinue the indwelling urinary catheter, but that she didn ' t " know what happened there. " Review of Resident #12 ' s clinical record " Diagnostics " dated 1/4/13 documented Resident #12 ' s urinalysis, culture and sensitivity documented she had Proteus mirabilis and [DIAGNOSES REDACTED] oxytoca in her urine. Proteus mirabilis and [DIAGNOSES REDACTED] oxytoca are commonly found in fecal material (stool). Review of Resident #17 ' s admission record documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #17 ' s clinical record " Diagnostics " dated 2/3/13 documented her urine contained Proteus mirabilis which is commonly found in fecal material (stool). The Administrator, DON, RNC #1 was informed 3/22/13 at 10:45 a.m. that Immediate Jeopardy was declared. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "3/22/13 revised 3/27/13" accepted at 11:00 a.m. documented ".....The Immediate Jeopardy was declared at 10:45 a.m. on 3/22/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education being presented to the facility staff nurses by the Director of Nursing/Unit Managers. - Incontinent Care - Foley Catheter Care - Foley Catheter Assessments and Documentation of color/clarity/characteristics by licensed nurse Re-education was started immediately with current staff in the facility: (copies of education provided is attached). In-service has been provided for licensed nurses for re-education regarding importance of Foley catheter care, documenting after Certified Nursing assistants provides Foley catheter care, and nurse assessment of patency of catheter, color and clarity of urine every shift. As of 3/26/13 at 11:30 a.m. all certified nursing assistants have been re-educated on incontinent care, Foley catheter care and successfully performed incontinent care observed by the Director of Nursing and/or Assistant Directors of Nursing using the skills checklist for incontinent care (sample attached). The exception is three certified nursing assistants who are prn (as needed) and are not scheduled. These three identified certified nursing assistants will not be allowed to work until they have been re-educated and successfully completed incontinent care using the skills checklist for incontinent care. All licensed charge nurses have been re-educated on Foley catheters and incontinent care including documentation. The exception is one PRN (as needed) licensed nurses who is not scheduled to work and will not be allowed to work until the re-education is completed. System Changes: There are no residents with Foley catheters in the facility as of 3/25/13 at 7:00 p.m. Future orders for Foley catheters will read: Change indwelling Foley catheters as needed prn dysfunction. Certified Nursing Assistants are required to not only documen

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for eight of 17 residents (Resident #1, #2, #3, #7,#8, #9, #11 and #12). Forty-five facility identified incontinent residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. An Immediate Jeopardy was identified on 3/22/13 at 10:45 a.m. While the Immediate Jeopardy was removed 3/27/13 at 11:00 a.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Seventy-one residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #3 ' s clinical record " Resident Admission Record " documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/29/11 documented she was admitted to the facility with an indwelling Foley catheter with a wound vac to her coccyx. Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 6/8/12 documented her Stage IV pressure ulcer to her coccyx had closed. Review of Resident #3 ' s clinical record there was no evidence of documentation of any calls to her physician or attempts to remove the Foley catheter since wound healing. Review of Resident #3 ' s clinical record " Minimum Data Set (MDS) " dated 2/17/13 documented under Speech Clarity Resident #3 was documented as having no speech - absence of spontaneous speech. Under Cognitive Skills for Daily Decision Making, it was documented as severely impaired - never/rarely made decisions. Under Functional Status, Bed Mobility, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Transfer, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Locomotion on Unit, Dressing, Toilet Use, Personal Hygiene, Resident #3 was documented as total dependence - full staff performance every time during entire 7 day period. Under Bladder and Bowel, Resident #3 was documented as having an indwelling Foley catheter for urine elimination and Ostomy for bowel movements. Review of Resident #3 ' s clinical record " Care Plan " dated 2/28/13 documented under Problem documented " .....I have a potential for compromised psychosocial well-being due to being a bed bound resident in the facility I reside in .... " Problem documented " ....Due to my health status I stay in my room. I like to listen to music or the TV. I need assistance turning the TV on, or on the radio, occasionally I attend to special events, and also I enjoy my family visits ..... " Problem documented " .....I am bedfast and my cognitive status/decision making skills are impaired ....I require extensive to total assistance with ADL ' s (Activities of Daily Living) .....Under Goal documented " ....I will have my needs anticipated and met by staff for 90 days .... " Review of Resident #3 ' s clinical record " Physician ' s Progress Notes " dated 3/19/13 untimed, documented " .....staff reported patient vomited twice over night ....up in wheelchair ....alert, no fever, no acute distress, will watch ....[MEDICATION NAME] (anti-emetic used for nausea/vomiting) prn (as needed) ... .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/18/13 at 2310 (11:10 p.m.) documented by LVN #7 " .....resident vomited times one, [MEDICATION NAME] as needed 25 mg po (by mouth) given ....HOB (head of bed) elevated ....physician notified ..... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0300 (3:00 a.m.) documented by LVN #7 " ... ...feeding resident, vomited again and physician ' s office notified .....order hold feeding and give [MEDICATION NAME] 25 mg po (per oral or by mouth) .... Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 0800 (8:00 a.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....respirations regular and non-labored, lung sounds clear to auscultation in front and back .....abdomen soft and non-distended ... ...bowel sounds in four quadrants ... ...[DEVICE] (an artificial opening on the abdomen that enters the stomach for the purpose of liquid feeding formula) patent and intact .....no signs/symptoms of aspiration noted .....Placement checked, no residual noted ....breakfast feedings held due to patient ate 50% of meal .....family called and notified about resident vomiting last night .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 10:00 a.m. documented by LVN #2 " ... ...resident resting in bed with eyes open, respirations regular and non-labored, lung sounds clear to auscultation in front and back .....[DEVICE] patent and intact ....Foley catheter patent and draining clear yellow urine ....[MEDICAL CONDITION] patent with soft stool in bag .....HOB elevated ...no distress noted at this time ... ... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 12:35 p.m. documented by LVN #2 " ... ...physician here to assess resident .....see progress notes .... " Review of Resident #3 ' s clinical record " Nurse ' s Notes " dated 3/19/13 at 1340 (1:40 p.m.) documented by LVN #2 " ... ...resident resting in bed with eyes closed ....HOB elevated ....Vital Signs (VS) blood pressure 118/54, heart rate 135, respirations 36, temperature 96.5, oxygen saturation 96%...accu-check (a finger stick used to collect blood to measure blood glucose (sugar) levels) 235 .....responding slightly to verbal stimuli ...diaphoretic and [MEDICAL CONDITION] .....lung sounds clear to auscultation, no nausea/vomiting noted ....Foley catheter patent draining clear yellow urine, [DEVICE] patent ....[MEDICAL CONDITION] patent with soft stool present .....send resident to emergency department for evaluation and treatment .....physician and family notified ..... " Record review of the local EMS (emergency medical services) " Run Sheet " dated 3/19/13 beginning at 1418 (2:18 p.m.) and ending at the local emergency department at 1432 (2:42 p.m.), when arrived at the local emergency department, documented " ....staff states patient vomited twice previously .....requesting transport for possible aspiration - patient has history of severe dementia .....tachypnea (rapid breathing), [MEDICAL CONDITION](rapid heart rate) [MEDICAL CONDITION] (low blood pressure) and diaphoresis (sweating) .....patient transferred to EMS cot via three person lift ....IV attempt twice was unsuccessful ....impression - septic shock ..... " Review of the EMS " Run Sheet " dated 3/19/13 at 1418 (2:18 p.m.) the first set of vital signs were documented the blood pressure as 89/53, pulse 134, respirations 20. Observation on 3/21/13 at 9:00 a.m. at the local hospital Intensive Care Unit revealed Resident #3 had a large unstageable pressure sore on her right heel. In an interview on 3/22/13 at 1:10 p.m. the Emergency Department Registered Nurse that received Resident #3 into the emergency department stated that when she received Resident #3 from the emergency medical services, Resident #3 was not alert, her rectal temperature was elevated and her Foley catheter was draining thick gray pus. She stated that Resident #3 was in a very bad state, diaphoretic (soaked in sweat) and had a general bad odor about her. She stated that Resident #3 was very dirty when she arrived to the emergency room . In an interview on 3/21/13 at 8:15 a.m. Intensive Care Unit (ICU) nurse (ICU nurse #1) that had care for Resident #3 when she was first admitted to the ICU stated that when she received Resident #3 from the emergency room , that Resident #3 was filthy and her Foley catheter had sludge in the tubing clotting off the urine from going into the drainage collection bag. She described the urine as cloudy, nasty green/gray in color and when she removed the Foley that she came to the hospital with from the facility, the tubing was stained and dirty. ICU nurse #1 described that when she removed the old Foley, there were three ICU nurses in the room assisting and two of the ICU nurse ' s had to leave the room vomiting from the overwhelming odor of the urine that saturated the bedding of Resident #3. She stated that after placing a new Foley catheter in Resident #3 and after Resident #3 urinated and soaked the entire bed, Resident #3 voided almost 500 cc (cubic centimeters) of cloudy, dark, thick urine. She stated that Resident #3 had dried stool on her buttocks and abdomen. She stated that she had given Resident #3 two head to toe bed baths during her shift and Resident #3 still was not clean when she turned over care to the oncoming nurse. In an interview on 3/25/13 at 10:50 a.m. Intensive Care Unit (ICU) nurse #2 that took over care of Resident #3 stated that she also gave Resident #3 two complete head to toe bed baths and finally got her cleaned up. She stated that she had called the facility asking when Resident #3 ' s Foley catheter was last changed and the DON told her that it was 2/25/13. The ICU nurse stated that she also informed the DON at the facility that when Resident #3 arrived, she was filthy and her urine was thick, gray sludge and wanted to know how Resident #3 had been cared for. In an interview on 3/21/13 at 8:30 a.m. Resident #3 ' s four daughters were present and stated that the first time they heard of their mother being admitted to the intensive care unit (ICU) was 3/19/13 at night (they were not sure at what time, but it was late evening) when the ICU nurse called them to come see their mother, that she was in critical condition and was not expected to survive. The daughters stated that they had called the facility and spoken with the Administrator and DON about their care concerns for Resident #3. The daughters stated that they had placed a sign above their mother ' s bed with times to be up in the Geri-chair and when to be placed back in bed. They stated that often times their mother would be in the same clothes for several days at a time, that her eyes were frequently matted and the CNA ' s would often leave her dirty frequently. They also stated that there was one CNA that manually picked their mother up from the Geri-chair by herself and placed their mother onto the bed. They stated that their mother was to be transferred by the Hoyer lift only and with two person assist. Review of the local hospital ' s medical records for Resident #3 documented by the first ICU nurse on 3/19/13 at 2100 (9:00 p.m.) documented " ... ....Patient Diagnosis: [REDACTED]..catheter removed and replaced on admission ....Patient voided a large amount of urine incontinently immediately after catheter was removed ... ...urine foul smelling, dark, cloudy and concentrated ....New Foley catheter inserted ..... " Review of the local hospitals medical records for Resident #3 documented by the first ICU nurse on 3/21/13 at 8:00 a.m. " ... ....I received the patient 3/19/13 and her Foley catheter appeared extremely dirty ....urine was very cloudy, a grey-amber color and had an overwhelmingly foul odor ....There was minimal urine output in the bag and urine was stationary in the tubing .....Upon taking out the Foley catheter, patient voided a great amount of urine described above ...after inserting the new catheter, patient immediately had out 450cc of urine described above ....patient was very unclean .... " Review of the hospital ' s " Patient Results " dated 3/19/13 at 1531 (3:51 p.m.) documented the culture and sensitivity (C&S) results as Proteus Mirabilis and Escherichia Coli (both are bacteria commonly found in feces {stool}). Observation on 3/21/13 at 7:50 a.m. at the local hospital Intensive Care Unit (ICU) revealed that Resident #3 had an Indwelling Foley Catheter draining thick, dark amber urine. The ICU nurse caring for Resident #3 stated that the urine looked " so much better " than when she first received her. At this time, Resident #3 was being transferred to another unit at the hospital. Observation on 3/21/13 at 8:45 a.m. at the local hospital in a regular hospital room revealed Resident #3 had an unstageable pressure ulcer located on her right heel that the facility had no evidence of documentation. Also she had two stage II pressure ulcers on the lateral aspect of her right foot. In an interview on 3/22/13 at 10:10 a.m. LVN #3 stated that she had changed the indwelling urinary catheter on Resident #3 on 2/25/13 when she was still working nights. She stated that the nurse working on the west side stated she did not know how to change an indwelling urinary catheter on a resident that was contracted. LVN #3 stated that the old urinary catheter had sediment in the tubing clogging off the flow of urine into the collection bag. LVN #3 stated that when she placed the new indwelling urinary catheter it immediately began draining without any difficulties. LVN #3 stated that she did not detect any odor about Resident #3 or the urine when she changed the catheter on 2/25/13. LVN #3 stated that she did not notify the physician due to the amount of sediment in the catheter tubing. LVN #3 stated that in her professional opinion indwelling urinary catheters should be changed at least once a month or more often if needed. LVN #3 stated in her professional opinion that it would take a very long time for urine to go from clear yellow to thick gray sludge, she was unable to give an estimate on how long it would take. In an interview on 3/21/13 at 11:30 a.m. ADON #2 accompanied this investigator to see the residents that was on the CMS Form 672 dated 3/21/13 that documented the facility having four residents in the facility as having a Foley catheter. Observation at this time revealed only one other resident (Resident #1) as having an indwelling urinary catheter. Resident #12 had not had a Foley catheter " ....for the past three weeks, she pulled her catheter out and hospice said to leave it out .... " There was no evidence of documentation of a physician order [REDACTED]. Resident #6 had not had a catheter since before 10/5/13 when hospice performed an in and out catherization to obtain urine for a urinalysis and culture and sensitivity for a suspected urinary tract infection. ADON #2 stated sarcastically " ....evidently I really know my residents ..... " There was no evidence of documentation of an order to take or leave the catheter out. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that in her professional opinion Foley catheters should be changed monthly. She also stated that some nurse aides measure the urine and document it and some aides only document urine amounts as small, medium or large. In an interview on 3/22/13 at 10:45 a.m. ADON #2 stated that the assessment completed on Resident #3 was a wrong assessment because the nurse did not do a head to toe assessment and the documentation on the assessment documented Resident #3 ' s urine as clear yellow urine. She stated that LVN#2 did not do a complete assessment of Resident #3 due to the fact that LVN #2 had not documented in Resident #3 ' s clinical record regarding the color and clarity of Resident #3 ' s urine until 3/19/13. In an interview on 3/25/13 at 11:39 a.m. CNA #3 stated that she had emptied Resident #3 ' s drainage bag on 3/19/13 before she went off shift at 6:00 a.m. and at that time the urine in the drainage bag was yellow and had bacteria in it. She explained that by having bacteria in the urine she meant that the urine was white and cloudy and to her it looked like this white cloudy stuff was clogging the tubing. She stated that she reported it to the day nurse who was LVN #2. In an interview on 3/22/13 at 11:00 a.m. LVN #2 stated that Resident #3 had vomited twice the night before (3/18/13) she was sent to the hospital. He stated that Resident #3 ate breakfast in bed but did not eat any lunch. The physician saw her and said she was fine. A few hours later (approximately 55 minutes) she started sweating a lot and her pulse rate got fast. LVN #2 stated that Resident #3 was mumbling and not doing the stuff she normally does. After lunch she was not responding, was breathing fast and was sweaty. LVN #2 described Resident #3 ' s urine as being yellow, clear and draining, but he was unable to state how much he observed in the bag at the time of the transfer. In an interview on 3/22/13 at 11:10 a.m. LVN #1 stated that if a resident with a urinary catheter had appeared to have a urinary tract infection it would be best to go ahead and change the catheter, even if waiting on a urinalysis. In an interview on 3/22/13 at 11:15 a.m. LVN #1 stated there were no open areas on Resident #3 ' s feet and that he had assess her skin the morning prior to her being sent to the emergency department and that he did not look at her urine. In an interview on 3/22/13 at 12:20 p.m. the Medical Director for the facility stated that he was unaware that the facility had changed their policy of changing indwelling urinary catheters monthly to as needed. He stated that in his professional medical opinion, urinary catheters needed to be changed at least once a month or sooner if needed. He stated that " .....I just don ' t know what to do with that facility .... " In an interview on 3/22/13 at 3:05 p.m. the DON stated that she tracks bowel movements, oral and [DEVICE] administered intakes. She stated that she does not see anything on outputs (such as urine). She stated that the system goes down every day at 2:00 a.m. and 2:00 p.m. but it does not stay down for very long (she was unable to give an estimated amount of time the system would be down). She stated that she had been training staff on fluid intake. In an interview on 3/22/13 at 3:15 p.m. CNA #5 stated that when she worked with Resident #3 on 3/18/13 the urine was dark yellow and she did not think anything of it because since her employment began in August 2012, Resident #3 ' s urine had always been dark yellow with " stuff " in the tubing. CNA #5 stated that the reason she did not tell any of the charge nurses about the color and clarity of Resident #3 ' s urine was because the urine hadn ' t changed since she had begun working in August, 2012. In an interview on 3/22/13 at 3:25 p.m. CNA #6 stated that she would go and ask the nurse how to input color, consistency and amount of urine into the kiosk. She stated that it was very important to keep the catheter clean and to be very careful while completing peri-care because it they didn ' t want to give the residents who have indwelling urinary catheters an infection. In an interview on 3/24/13 at 8:20 a.m. RN #1 stated that she worked weekends, but had been off and had not worked with Resident #3 for over a month. During the interview she said that in her professional opinion indwelling urinary catheters should be change done a month or sooner if needed. RN #1 was no aware of any facility criteria for changing out urinary catheters. In an interview on 3/25/13 at 10:20 a.m. ADON #2 stated that the nurse who had been doing infection control left in January 2013 and that she (ADON #2) had been trying " to keep up with it " . She said she was not aware that Proteus Mirabalis was a fecal bacterium. She was not aware of any recent in-services on incontinent care. In an interview on 3/25/13 at 1:30 p.m. CNA #2 stated that the last time she had taken care (which was documented on the kiosk as 3/10/13) of Resident #3 she reported to the nurse that the urine was a dark brown color and that she did inform the charge nurse, but was unable to state which nurse she had reported this to. CNA #2 stated that it was the day charge nurse for the west side. Review of the facility ' s Infection Reports revealed two forms being used. One contained the questions " Health Care Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " which had yes or no answers. The second Infection Report Form documented " ....Facility Acquired Infection developed after admission? " and " Community Acquired Evidence of Infection at time of admission? " Both with yes or no answers. Seventeen Infection Reports of residents with UTI ' s were reviewed for whether they were marked to indicate if the UTI was an HAI or CAI. Nine of the reports had both questions marked " No " , seven had neither question answered, and one had HAI question left blank and answered " No " on the CAI question. In an interview on 3/26/13 at 10:50 a.m. with the DON, ADON #2 and RNC #1, RNC #1 stated that there were criteria for determining if a resident infection was a Healthcare Associated Infection (HAI) and ADON #2 pointed to the criteria listed on the HAI form. In an interview on 3/26/13 at 3:50 p.m. and 4:30 p.m. RNC #2 stated that on the Infection Report form the questions " Healthcare Associated Infection (HAI)? (Generally occurs after 72 hours from the time of admission) " and " Community Associated Infection? (Present or incubating at time of admission, or develops within 72 hours of admission) " should be answered either yes or no. If the HAI question is answered " yes " , then the Healthcare Associated Infection Surveillance Report Form should be filled out. RNC #2 stated that the Infection Control Policy criteria was to determine if there was an infection and the HAI Surveillance Report Form criteria was to help determine if the infection was chronic or acute. In an interview on 3/27/13 at 9:30 a.m. ADON #2 stated that she had no instruction on how to fill out the Infection Control Log. Review of Resident #1 ' s clinical record " Admission Record " undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Observation on 3/22/12 at 9:15 a.m. CNA #7 providing incontinent care to Resident #1 revealed CNA #7 rubbing back and forth with the same piece of cloth on the urinary catheter. CNA #7 then cleaned stool from an incontinent episode of bowel movement from the bottom up, spreading stool to vaginal/peri area. Observation on 3/21/13 at 3:40 p.m. revealed that Resident #1 ' s urinary catheter tubing contained dark amber urine with sediment in the tubing. ADON #2 stated that she thought the urine was yellow, but when questioned, she stated that she would call the urine amber. ADON #2 stated that with the sediment in the tubing and the color of the urine, she thought that Resident #1 might have a urinary tract infection. Review of Resident #1 ' s clinical record " Diagnostics " dated 3/19/13 documented Resident #1 ' s urine contained the bacterium Escherichia coli (which is intestinal bacteria). Review of Resident #2 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]., hypertension and [MEDICAL CONDITION]. Review of Resident #2 ' s clinical record " Diagnostics " dated 1/23/13 document her urine contained Escherichia coli, [MEDICATION NAME] cloacae, and proteus mirabilis which is commonly found in the intestines or fecal material. Review of Resident #7 ' s admission record undated documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #7 ' s clinical record " Diagnostics " dated 2/7/13 documented her urinalysis and culture and sensitivity contained Escherichia Coli which is intestinal bacteria. Review of Resident #8 ' s admission record undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #8 ' s clinical record " Diagnostics " dated 1/12/13 documented her urinalysis and culture and sensitivity contained Proteus mirabilis which is intestinal bacteria. Review of Resident #9 ' s admission record revealed she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9 ' s clinical record " Diagnostics " dated 2/5/13 documented her urinalysis and culture and sensitivity contained [MEDICATION NAME] Faecalis which is intestinal bacteria. Review of Resident #11 ' s admission record revealed he was an [AGE] year old male who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #11 ' s clinical record " Nurse ' s Notes " documented he was admitted to the facility on [DATE] with an indwelling urinary catheter. On the date of admission (3/14/13) at 6:40 p.m. he pulled the catheter out and it was re-inserted by nursing staff. Review of Resident #11 ' s clinical record " Admission Order " revealed no evidence of documentation for an indwelling urinary catheter. Review of Resident #11 ' s clinical record " Physician order [REDACTED]. Review of Resident #12 ' s clinical record " Resident Admission Record " undated documented that she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12 ' s clinical record " Nurse ' s Notes " dated 3/11/13 at 0840 (8:40 a.m.) documented " ... ...hospice notified the time of resident pulling out Foley catheter on previous shift, awaiting new orders(to be) called back from hospice .... " There was no evidence of documentation that hospice had called back or from the physician regarding to discontinue the Foley catheter. Review of Resident #12 ' s clinical record " Re-admission orders [REDACTED]. Review of Resident #12 ' s clinical record " Physician order [REDACTED]. Observation on 3/22/13 at 9:50 a.m. revealed that Resident #12 did not have an indwelling urinary catheter in place. In an interview on 3/22/13 at 10:42 a.m. ADON #2 stated that she had been told there was an order to discontinue Resident #12 ' s indwelling urinary catheter, but that she had not been able to find one in the clinical record. In an interview on 3/22/13 at 10:55 a.m. ADON #1 stated that she thought an order had been faxed to discontinue the indwelling urinary catheter, but that she didn ' t " know what happened there. " Review of Resident #12 ' s clinical record " Diagnostics " dated 1/4/13 documented Resident #12 ' s urinalysis, culture and sensitivity documented she had Proteus mirabilis and [DIAGNOSES REDACTED] oxytoca in her urine. Proteus mirabilis and [DIAGNOSES REDACTED] oxytoca are commonly found in fecal material (stool). Review of Resident #17 ' s admission record documented she was an [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #17 ' s clinical record " Diagnostics " dated 2/3/13 documented her urine contained Proteus mirabilis which is commonly found in fecal material (stool). The Administrator, DON, RNC #1 was informed 3/22/13 at 10:45 a.m. that Immediate Jeopardy was declared. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "3/22/13 revised 3/27/13" accepted at 11:00 a.m. documented ".....The Immediate Jeopardy was declared at 10:45 a.m. on 3/22/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education being presented to the facility staff nurses by the Director of Nursing/Unit Managers. - Incontinent Care - Foley Catheter Care - Foley Catheter Assessments and Documentation of color/clarity/characteristics by licensed nurse Re-education was started immediately with current staff in the facility: (copies of education provided is attached). In-service has been provided for licensed nurses for re-education regarding importance of Foley catheter care, documenting after Certified Nursing assistants provides Foley catheter care, and nurse assessment of patency of catheter, color and clarity of urine every shift. As of 3/26/13 at 11:30 a.m. all certified nursing assistants have been re-educated on incontinent care, Foley catheter care and successfully performed incontinent care observed by the Director of Nursing and/or Assistant Directors of Nursing using the skills checklist for incontinent care (sample attached). The exception is three certified nursing assistants who are prn (as needed) and are not scheduled. These three identified certified nursing assistants will not be allowed to work until they have been re-educated and successfully completed incontinent care using the skills checklist for incontinent care. All licensed charge nurses have been re-educated on Foley catheters and incontinent care including documentation. The exception is one PRN (as needed) licensed nurses who is not scheduled to work and will not be allowed to work until the re-education is completed. System Changes: There are no residents with Foley catheters in the facility as of 3/25/13 at 7:00 p.m. Future orders for Foley catheters will read: Change indwelling Foley catheters as needed prn dysfunction. Certified Nursing Assistants are required to not only document urine output of resident ' s with Foley catheters in the Kiosk with the amount of urine in cc ' s (cubic centimeters) on their shift, but also report to the nurse if they notice any changes in urine color and if there is absence of urine output at any time during their shift. At that time, the charge nurse will assess the resid

Based on observation, interview and record review the facility failed to notify and consult with the physician and/or legal representative regarding significan changes in the physical/clinical status for one of 11 residents (Resident #2). The facility failed to assess Resident #2, consult her physician, or honor her requests to go to the hospital when she began complaining of chest pain on 1/25/13 through 1/31/13. Resident #2 was given [MEDICATION NAME] (anti-psychotic) on 1/25/13 and [MEDICATION NAME] (heartburn) on 1/26/13 for complaints of chest pain. On 01/31/13 Resident #2 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy was identified on 2/19/13 at 9:56 a.m. While the Immediate Jeopardy was removed 2/20/12 at 1:50 p.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Sixty-eight residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of the facility's "Abuse, Neglect and Misappropriation of Property" Administrative Policies and Procedures dated 2/08 documented "....all alleged violations concerning abuse, neglect or misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies, according to state law including the State Survey and Certfication Agency......the facility maintains that all allegations of abuse, neglect, misappropriation of property, etc., are thoroughly investigated and appropriate acitons are taken....." Review of Resident #2's clinical record "Resident Admission Record" undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's clinical record "Admission Data Collection Tool" dated 1/23/13 documented under "...Active Diagnois in last 7 days....cancer with metastasis bone, brain, lung and liver....diabetes mellitus, asthma, left [PROCEDURE], [DIAGNOSES REDACTED] with a VP shunt and osteonecrosis of jaw....." Under the Nurse's Comment/Documentation documented "....received [AGE] year old female from local hospital via Geri-chair; alert unable to hear questions asked, requessts eraser board to write questions; continuously life eye lid to left eye to see nurse....Able to respond to questions, offered to feed regular food items, requested to wait until husband arrives, knows where she is, how many children she has, knows where pain is located; states repositioning my back and pain eases up.....requires extensive assistance for ADL's; incontinent of bowel and bladder......" Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/25/13 documented ".....at 1400 (2:00 p.m.) resident anxious, yelling out inconsolable, resident did take prn (as needed) [MEDICATION NAME] (anti-anxiety medication) but refused [MEDICATION NAME] (narcotic pain reliever) after three attempts ... ...at 1530 (3:30 p.m.) ....received fax order for [MEDICATION NAME] 2mg IM (intramuscular) every four hours as needed for agitation .....medication taken from e-kit (emergency box) and administered in left hip .... In an untimed entry for 1/25/13 documented " .....resident agitated, [MEDICATION NAME] 2mg given in left deltoid ....." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 10:15 a.m. documented " .....late entry for 1/26/13 at 1300 (1:00 p.m.) .... Family reports complaints of chest pain ... ...probably indigestion, [MEDICATION NAME] given at approximately 1315 (1:15 p.m.) .....no further chest pain ....." In a telephone interview on 2/19/13 at 8:15 a.m. LVN #1 stated that she had given [MEDICATION NAME] to Resident #2. She stated that her charge nurse, LVN #3 had told her to give [MEDICATION NAME] and did not tell her that Resident #2 was having chest pain and she did not do an assessment. In an interview on 2/19/13 at 8:35 a.m. LVN #3 verbally denied any knowledge of Resident #2 having chest pain. Review of Resident #2's clinical record "Nurse's Notes" dated 1/29/13 at 8:05 a.m. documented "......refuses to allow nurse to take vital signs ......complains of pain to left breast area ...." Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/30/13 documented "......resident yells repeatedly "help me, I need to get out of here" .....at 1600 (4:00 p.m.) "......resident family reports complaints of chest pain, resident denies chest pain ...." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 untimed documented "......late entry for 1/30/13 at 1600 (4:00 p.m.) resident's family reports complaints of chest pain ......" There was no evidence of documentation that nursing assessments or interventions were attempted. Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 9:40 a.m. documented "......resident's sister approached me in hall regarding resident complaint of chest pain for four days that hadn't been addressed to her knowledge .....explained that this was the first time {this nurse} was hearing of it, explained I'd call her physician and get an order at that point the sister informed me that she already called the physician and that the physician told her that the facility has a doctor to take care of that ....I explained to the sister that the physician is listed as primary doctor and that any orders regarding the resident would have to come from that physician .....I did explain that I would call the medical director and get an order for [REDACTED].the sister was very thankful ... ...spoke with medical director and received a verbal order for the chest x-ray and EKG ......" Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 1310 (1:10 p.m.) documented ".....resident complains of chest pain, new order for portable EKG and chest x-ray ....." Observation on 1/31/13 at approximately 1:00 p.m. to 1:15 p.m. overheard Resident #2's spouse in hallway yelling for Resident to go to the local emergency room since she was having chest pain for the past several days. Overheard the DON speaking with Resident #2's spouse about how the facility does not have a physician that stays at the facility, but she would call the medical director if he wished ... ...At that point the DON stated that she would call EMS for Resident #2. Review of Resident #2's clinical record revealed no evidence of further documentation. In a telephone interview on 2/20/13 at 1:11 p.m. Resident #2's sister stated that Resident #2 began complaining of chest pain on Friday, 1/25/13 and the nurses gave her a shot to calm her down and didn't do anything for her chest pain. Finally on 1/31/13 my brother-in-law (Resident #2's spouse) insisted that the facility send her to the local emergency room . Review of Resident #2's clinical record from the local hospital "Patient Record" dated 1/31/13 documented the admitting [DIAGNOSES REDACTED]. Review of Resident #2's clinical record from the local hospital "EKG" dated 1/31/13 at 14:48 (2:48 p.m.) documented ".....ST and Marked T-wave abnormality, consider inferolateral ischemia ....prolonged QT .....abnormal EKG ...." Review of Resident #2's clinical record from the local hospital "History and Physical" dated 1/31/13 documented "......acute coronary syndrome; slight elevation of troponin and a very abnormal EKG indicating the patient most likely have acute coronary syndrome, most likely the patient had non-ST-elevation [MEDICAL CONDITION] infarction (MI -[MEDICAL CONDITION]) .....patient taken to cardiac catheterization lab ......" In an interview on 2/15/13 at 2:50 p.m. ADON stated that she felt that maybe the nurse didn't feel that Resident #2's chest pain was actually chest pain and that was the reason that the nurse gave her [MEDICATION NAME]. She acknowledged that a cardiac assessment was not documented. She stated that on 1/31/13 Resident #2's sister approached her about Resident #2's chest pain and that was when she called the medical director and obtained orders for a chest x-ray and EKG. She stated that she was told the reason Resident #2 was shipped to the local emergency room was because of an abnormal EKG. In an interview on 2/15/13 at 3:30 p.m. the DON stated that the facility should have called EMS to transport Resident #2 sooner due to Resident #2 requesting to go to the emergency room with chest pain. She stated that the normal practice at the facility is when a resident request to go to the local emergency room was to send them. She stated that with Resident #2's history of anxiety and with her [DIAGNOSES REDACTED]. In an interview on 2/15/13 at 4:10 p.m. LVN #2 stated that Resident #2 complained of pain in her breast area on 1/29/13 and requested to go to the local emergency room . She stated that she called the spouse to come in and speak with Resident #2 and called Resident #2's sister to come speak with her. She stated that Resident #2 kept calling out to go to the local emergency room . In an interview on 2/19/13 at 9:00 a.m. the DON stated that LVN #1 had given [MEDICATION NAME] to Resident #2 and that is was not in the LVN scope of practice to diagnose breast pain vs. chest pain. In an interview on 02/19/13 at 4:20 p.m., Resident #2 said, "I want to tell you about that horrible place. " She said she told staff she had chest pain, but no one did anything about it. Resident #2 said she told staff to take her to the hospital because of her chest pain. She said staff ignored her, and that the thought of the facility made her "skin crawl." Resident #2 said she prayed, and then she and her sister told the facility to take her to the hospital. Review of the facility's "Nursing Policies and Procedures - Physician Communication Grid" dated 9/11 documented for chest pain treatment is required within one hour. This also documented ".....these guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event. The above applies 24 hours a day, seven days a week ....." Review of the facility's "Nursing Policies and Procedures .....Physician Communication/Change in Condition" dated 9/11 documented "....the provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient/resident's condition ... ....complete assessment of the resident .....notify the physician of the change in medical condition ....the nurse will document all assessments and changes in the resident ' s condition in the medical record ...." On 2/19/13 at 9:56 a.m. the Administrator and DON were informed of Immediate Jeopardy Status. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "2/19/12 revised 2/20/13" received at 1:20 p.m. documented ".....On 1/1/13 an in-service was conducted on: - Change of Condition and Chest Pain - Hygiene - Resident request for Ambulance or ER services The Immediate Jeopardy was declared at 9:56 a.m. on 2/19/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education presented to the facility staff nurses by the Director of Nursing. - Resident Assessments - Detail Description and Demonstration of Head to Toe Assessment - Discussion of Normal and Abnormal Findings - Documentation of Assessments As of 10:00 a.m. on 2/20/13 all staff nurse have been re-educated. - Re-education for Licensed Nurses regarding importance of accurate assessment, accurate documentation, and reporting change in condition to physician and family. Nurses will perform timely assessments of residents with change of condition and document same. Residents with a known aspiration risk will be positioned with head of the bed elevated. This re-education was performed by the Director of Nursing/Assistant Directors of Nursing. Licensed Nurses who have not had the re-education will not be permitted to perform patient care without having the re-education. - Certified Nursing Assistants will be re-educated regarding the importance of recognizing and reporting changes in condition to the charge nurse. Re-education will include raising the head of the bed for residents who have been vomiting or are at risk of aspiration. Certified Nursing Assistants will be alerted to these new risk factors by the charge nurse as they occur. - The Director of Nursing/Assistant Director of Nursing has been monitoring the resident care areas, discussing any change of condition with the charge nurses throughout the work day and monitoring the 24 hour report for change of condition. Charge nurses have been instructed to call the DON with change of conditions to discuss actions taken and further actions needed. Charts of residents with change of condition during the 24 hour period are being reviewed to ensure that proper actions are being taken with change of condition, notifications were made, and any new orders have been implemented. This monitoring is being performed by the Director of Nursing/Assistant Directors of Nursing on a daily basis during the week and weekend RN on the weekend. - The resident's physician and Medical Director have been made aware of the alleged deficient practice and plans in place to correct. - The Performance Improvement Committee will review the above actions taken by the facility to correct the alleged deficient practice. - The Director of Nursing will report progress to the Performance Improvement Committee monthly for three months and then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions ....." In an interview on 02/20/13 at 8:10 a.m., LVN #5 said he received in-services 02/19/13 regarding change in condition and assessments. LVN #5 said that if a resident had a change in condition, nurses were to obtain vital signs, call the physician, and notify the family and DON. LVN #5 said all findings were to be documented, and that if a resident requested, staff were to send them to the hospital. In an interview on 02/20/13 at 8:16 a.m., LVN #6 said in-services were held 02/19/13 on assessment of residents and assessing changes in condition. LVN #6 said if a resident had a change in condition, nurses were to send them to the hospital instead of trying to figure out the problem. He said if a resident had a change in condition, he would notify the physician, family and DON, and document the events. In an interview on 02/20/13 at 8:40 a.m., LVN #3 said he received training 02/19/13 on full body assessments. He said he was told to get vital signs, notify the physician, and call the family and the DON. LVN #3 said if a resident had a change in condition, he would send them to the emergency room and document everything in the nurse's notes. In an interview on 2/20/13 at 2:15 p.m. LVN #4 stated that she had received in-service on 2/19/13 at 4:00 p.m. concerning the resident change of condition, complaints of chest pain, or requests to go to the emergency room . She stated that the DON stressed the importance of sending any resident who presents with any of the above to immediately send the resident to the local emergency room and to be sure and make detailed documentation. On 2/20/12 at 1:50 p.m. the Immediate Jeopardy was lowered to a scope and severity of actual harm that is not Immediate Jeopardy level at a pattern. CMS Form 672 dated 2/15/13 documented a census of 68.

Based on observation, interview and record review the facility failed to notify and consult with the physician and/or legal representative regarding significan changes in the physical/clinical status for one of 11 residents (Resident #2). The facility failed to assess Resident #2, consult her physician, or honor her requests to go to the hospital when she began complaining of chest pain on 1/25/13 through 1/31/13. Resident #2 was given [MEDICATION NAME] (anti-psychotic) on 1/25/13 and [MEDICATION NAME] (heartburn) on 1/26/13 for complaints of chest pain. On 01/31/13 Resident #2 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy was identified on 2/19/13 at 9:56 a.m. While the Immediate Jeopardy was removed 2/20/12 at 1:50 p.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Sixty-eight residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #2's clinical record "Resident Admission Record" undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's clinical record "Admission Data Collection Tool" dated 1/23/13 documented under "...Active Diagnois in last 7 days....cancer with metastasis bone, brain, lung and liver....diabetes mellitus, asthma, left [PROCEDURE], [DIAGNOSES REDACTED] with a VP shunt and osteonecrosis of jaw....." Under the Nurse's Comment/Documentation documented "....received [AGE] year old female from local hospital via Geri-chair; alert unable to hear questions asked, requessts eraser board to write questions; continuously life eye lid to left eye to see nurse....Able to respond to questions, offered to feed regular food items, requested to wait until husband arrives, knows where she is, how many children she has, knows where pain is located; states repositioning my back and pain eases up.....requires extensive assistance for ADL's; incontinent of bowel and bladder......" Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/25/13 documented ".....at 1400 (2:00 p.m.) resident anxious, yelling out inconsolable, resident did take prn (as needed) [MEDICATION NAME] (anti-anxiety medication) but refused [MEDICATION NAME] (narcotic pain reliever) after three attempts ... ...at 1530 (3:30 p.m.) ....received fax order for [MEDICATION NAME] 2mg IM (intramuscular) every four hours as needed for agitation .....medication taken from e-kit (emergency box) and administered in left hip .... In an untimed entry for 1/25/13 documented " .....resident agitated, [MEDICATION NAME] 2mg given in left deltoid ....." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 10:15 a.m. documented " .....late entry for 1/26/13 at 1300 (1:00 p.m.) .... Family reports complaints of chest pain ... ...probably indigestion, [MEDICATION NAME] given at approximately 1315 (1:15 p.m.) .....no further chest pain ....." In a telephone interview on 2/19/13 at 8:15 a.m. LVN #1 stated that she had given [MEDICATION NAME] to Resident #2. She stated that her charge nurse, LVN #3 had told her to give [MEDICATION NAME] and did not tell her that Resident #2 was having chest pain and she did not do an assessment. In an interview on 2/19/13 at 8:35 a.m. LVN #3 verbally denied any knowledge of Resident #2 having chest pain. Review of Resident #2's clinical record "Nurse's Notes" dated 1/29/13 at 8:05 a.m. documented "......refuses to allow nurse to take vital signs ......complains of pain to left breast area ...." Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/30/13 documented "......resident yells repeatedly "help me, I need to get out of here" .....at 1600 (4:00 p.m.) "......resident family reports complaints of chest pain, resident denies chest pain ...." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 untimed documented "......late entry for 1/30/13 at 1600 (4:00 p.m.) resident's family reports complaints of chest pain ......" There was no evidence of documentation that nursing assessments or interventions were attempted. Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 9:40 a.m. documented "......resident's sister approached me in hall regarding resident complaint of chest pain for four days that hadn't been addressed to her knowledge .....explained that this was the first time {this nurse} was hearing of it, explained I'd call her physician and get an order at that point the sister informed me that she already called the physician and that the physician told her that the facility has a doctor to take care of that ....I explained to the sister that the physician is listed as primary doctor and that any orders regarding the resident would have to come from that physician .....I did explain that I would call the medical director and get an order for [REDACTED].the sister was very thankful ... ...spoke with medical director and received a verbal order for the chest x-ray and EKG ......" Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 1310 (1:10 p.m.) documented ".....resident complains of chest pain, new order for portable EKG and chest x-ray ....." Observation on 1/31/13 at approximately 1:00 p.m. to 1:15 p.m. overheard Resident #2's spouse in hallway yelling for Resident to go to the local emergency room since she was having chest pain for the past several days. Overheard the DON speaking with Resident #2's spouse about how the facility does not have a physician that stays at the facility, but she would call the medical director if he wished ... ...At that point the DON stated that she would call EMS for Resident #2. Review of Resident #2's clinical record revealed no evidence of further documentation. In a telephone interview on 2/20/13 at 1:11 p.m. Resident #2's sister stated that Resident #2 began complaining of chest pain on Friday, 1/25/13 and the nurses gave her a shot to calm her down and didn't do anything for her chest pain. Finally on 1/31/13 my brother-in-law (Resident #2's spouse) insisted that the facility send her to the local emergency room . Review of Resident #2's clinical record from the local hospital "Patient Record" dated 1/31/13 documented the admitting [DIAGNOSES REDACTED]. Review of Resident #2's clinical record from the local hospital "EKG" dated 1/31/13 at 14:48 (2:48 p.m.) documented ".....ST and Marked T-wave abnormality, consider inferolateral ischemia ....prolonged QT .....abnormal EKG ...." Review of Resident #2's clinical record from the local hospital "History and Physical" dated 1/31/13 documented "......acute coronary syndrome; slight elevation of troponin and a very abnormal EKG indicating the patient most likely have acute coronary syndrome, most likely the patient had non-ST-elevation [MEDICAL CONDITION] infarction (MI -[MEDICAL CONDITION]) .....patient taken to cardiac catheterization lab ......" In an interview on 2/15/13 at 2:50 p.m. ADON stated that she felt that maybe the nurse didn't feel that Resident #2's chest pain was actually chest pain and that was the reason that the nurse gave her [MEDICATION NAME]. She acknowledged that a cardiac assessment was not documented. She stated that on 1/31/13 Resident #2's sister approached her about Resident #2's chest pain and that was when she called the medical director and obtained orders for a chest x-ray and EKG. She stated that she was told the reason Resident #2 was shipped to the local emergency room was because of an abnormal EKG. In an interview on 2/15/13 at 3:30 p.m. the DON stated that the facility should have called EMS to transport Resident #2 sooner due to Resident #2 requesting to go to the emergency room with chest pain. She stated that the normal practice at the facility is when a resident request to go to the local emergency room was to send them. She stated that with Resident #2's history of anxiety and with her [DIAGNOSES REDACTED]. In an interview on 2/15/13 at 4:10 p.m. LVN #2 stated that Resident #2 complained of pain in her breast area on 1/29/13 and requested to go to the local emergency room . She stated that she called the spouse to come in and speak with Resident #2 and called Resident #2's sister to come speak with her. She stated that Resident #2 kept calling out to go to the local emergency room . In an interview on 2/19/13 at 9:00 a.m. the DON stated that LVN #1 had given [MEDICATION NAME] to Resident #2 and that is was not in the LVN scope of practice to diagnose breast pain vs. chest pain. In an interview on 02/19/13 at 4:20 p.m., Resident #2 said, "I want to tell you about that horrible place. " She said she told staff she had chest pain, but no one did anything about it. Resident #2 said she told staff to take her to the hospital because of her chest pain. She said staff ignored her, and that the thought of the facility made her "skin crawl." Resident #2 said she prayed, and then she and her sister told the facility to take her to the hospital. Review of the facility's "Nursing Policies and Procedures - Physician Communication Grid" dated 9/11 documented for chest pain treatment is required within one hour. This also documented ".....these guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event. The above applies 24 hours a day, seven days a week ....." Review of the facility's "Nursing Policies and Procedures .....Physician Communication/Change in Condition" dated 9/11 documented "....the provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient/resident's condition ... ....complete assessment of the resident .....notify the physician of the change in medical condition ....the nurse will document all assessments and changes in the resident ' s condition in the medical record ...." On 2/19/13 at 9:56 a.m. the Administrator and DON were informed of Immediate Jeopardy Status. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "2/19/12 revised 2/20/13" received at 1:20 p.m. documented ".....On 1/1/13 an in-service was conducted on: - Change of Condition and Chest Pain - Hygiene - Resident request for Ambulance or ER services The Immediate Jeopardy was declared at 9:56 a.m. on 2/19/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education presented to the facility staff nurses by the Director of Nursing. - Resident Assessments - Detail Description and Demonstration of Head to Toe Assessment - Discussion of Normal and Abnormal Findings - Documentation of Assessments As of 10:00 a.m. on 2/20/13 all staff nurse have been re-educated. - Re-education for Licensed Nurses regarding importance of accurate assessment, accurate documentation, and reporting change in condition to physician and family. Nurses will perform timely assessments of residents with change of condition and document same. Residents with a known aspiration risk will be positioned with head of the bed elevated. This re-education was performed by the Director of Nursing/Assistant Directors of Nursing. Licensed Nurses who have not had the re-education will not be permitted to perform patient care without having the re-education. - Certified Nursing Assistants will be re-educated regarding the importance of recognizing and reporting changes in condition to the charge nurse. Re-education will include raising the head of the bed for residents who have been vomiting or are at risk of aspiration. Certified Nursing Assistants will be alerted to these new risk factors by the charge nurse as they occur. - The Director of Nursing/Assistant Director of Nursing has been monitoring the resident care areas, discussing any change of condition with the charge nurses throughout the work day and monitoring the 24 hour report for change of condition. Charge nurses have been instructed to call the DON with change of conditions to discuss actions taken and further actions needed. Charts of residents with change of condition during the 24 hour period are being reviewed to ensure that proper actions are being taken with change of condition, notifications were made, and any new orders have been implemented. This monitoring is being performed by the Director of Nursing/Assistant Directors of Nursing on a daily basis during the week and weekend RN on the weekend. - The resident's physician and Medical Director have been made aware of the alleged deficient practice and plans in place to correct. - The Performance Improvement Committee will review the above actions taken by the facility to correct the alleged deficient practice. - The Director of Nursing will report progress to the Performance Improvement Committee monthly for three months and then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions ....." In an interview on 02/20/13 at 8:10 a.m., LVN #5 said he received in-services 02/19/13 regarding change in condition and assessments. LVN #5 said that if a resident had a change in condition, nurses were to obtain vital signs, call the physician, and notify the family and DON. LVN #5 said all findings were to be documented, and that if a resident requested, staff were to send them to the hospital. In an interview on 02/20/13 at 8:16 a.m., LVN #6 said in-services were held 02/19/13 on assessment of residents and assessing changes in condition. LVN #6 said if a resident had a change in condition, nurses were to send them to the hospital instead of trying to figure out the problem. He said if a resident had a change in condition, he would notify the physician, family and DON, and document the events. In an interview on 02/20/13 at 8:40 a.m., LVN #3 said he received training 02/19/13 on full body assessments. He said he was told to get vital signs, notify the physician, and call the family and the DON. LVN #3 said if a resident had a change in condition, he would send them to the emergency room and document everything in the nurse's notes. In an interview on 2/20/13 at 2:15 p.m. LVN #4 stated that she had received in-service on 2/19/13 at 4:00 p.m. concerning the resident change of condition, complaints of chest pain, or requests to go to the emergency room . She stated that the DON stressed the importance of sending any resident who presents with any of the above to immediately send the resident to the local emergency room and to be sure and make detailed documentation. On 2/20/12 at 1:50 p.m. the Immediate Jeopardy was lowered to a scope and severity of actual harm that is not Immediate Jeopardy level at a pattern. CMS Form 672 dated 2/15/13 documented a census of 68.

Based on observation, interview and record review the facility failed to notify and consult with the physician and/or legal representative regarding significan changes in the physical/clinical status for one of 11 residents (Resident #2). The facility failed to assess Resident #2, consult her physician, or honor her requests to go to the hospital when she began complaining of chest pain on 1/25/13 through 1/31/13. Resident #2 was given [MEDICATION NAME] (anti-psychotic) on 1/25/13 and [MEDICATION NAME] (heartburn) on 1/26/13 for complaints of chest pain. On 01/31/13 Resident #2 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy was identified on 2/19/13 at 9:56 a.m. While the Immediate Jeopardy was removed 2/20/12 at 1:50 p.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Sixty-eight residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #2's clinical record "Resident Admission Record" undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's clinical record "Admission Data Collection Tool" dated 1/23/13 documented under "...Active Diagnois in last 7 days....cancer with metastasis bone, brain, lung and liver....diabetes mellitus, asthma, left [PROCEDURE], [DIAGNOSES REDACTED] with a VP shunt and osteonecrosis of jaw....." Under the Nurse's Comment/Documentation documented "....received [AGE] year old female from local hospital via Geri-chair; alert unable to hear questions asked, requessts eraser board to write questions; continuously life eye lid to left eye to see nurse....Able to respond to questions, offered to feed regular food items, requested to wait until husband arrives, knows where she is, how many children she has, knows where pain is located; states repositioning my back and pain eases up.....requires extensive assistance for ADL's; incontinent of bowel and bladder......" Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/25/13 documented ".....at 1400 (2:00 p.m.) resident anxious, yelling out inconsolable, resident did take prn (as needed) [MEDICATION NAME] (anti-anxiety medication) but refused [MEDICATION NAME] (narcotic pain reliever) after three attempts ... ...at 1530 (3:30 p.m.) ....received fax order for [MEDICATION NAME] 2mg IM (intramuscular) every four hours as needed for agitation .....medication taken from e-kit (emergency box) and administered in left hip .... In an untimed entry for 1/25/13 documented " .....resident agitated, [MEDICATION NAME] 2mg given in left deltoid ....." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 10:15 a.m. documented " .....late entry for 1/26/13 at 1300 (1:00 p.m.) .... Family reports complaints of chest pain ... ...probably indigestion, [MEDICATION NAME] given at approximately 1315 (1:15 p.m.) .....no further chest pain ....." In a telephone interview on 2/19/13 at 8:15 a.m. LVN #1 stated that she had given [MEDICATION NAME] to Resident #2. She stated that her charge nurse, LVN #3 had told her to give [MEDICATION NAME] and did not tell her that Resident #2 was having chest pain and she did not do an assessment. In an interview on 2/19/13 at 8:35 a.m. LVN #3 verbally denied any knowledge of Resident #2 having chest pain. Review of Resident #2's clinical record "Nurse's Notes" dated 1/29/13 at 8:05 a.m. documented "......refuses to allow nurse to take vital signs ......complains of pain to left breast area ...." Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/30/13 documented "......resident yells repeatedly "help me, I need to get out of here" .....at 1600 (4:00 p.m.) "......resident family reports complaints of chest pain, resident denies chest pain ...." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 untimed documented "......late entry for 1/30/13 at 1600 (4:00 p.m.) resident's family reports complaints of chest pain ......" There was no evidence of documentation that nursing assessments or interventions were attempted. Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 9:40 a.m. documented "......resident's sister approached me in hall regarding resident complaint of chest pain for four days that hadn't been addressed to her knowledge .....explained that this was the first time {this nurse} was hearing of it, explained I'd call her physician and get an order at that point the sister informed me that she already called the physician and that the physician told her that the facility has a doctor to take care of that ....I explained to the sister that the physician is listed as primary doctor and that any orders regarding the resident would have to come from that physician .....I did explain that I would call the medical director and get an order for [REDACTED].the sister was very thankful ... ...spoke with medical director and received a verbal order for the chest x-ray and EKG ......" Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 1310 (1:10 p.m.) documented ".....resident complains of chest pain, new order for portable EKG and chest x-ray ....." Observation on 1/31/13 at approximately 1:00 p.m. to 1:15 p.m. overheard Resident #2's spouse in hallway yelling for Resident to go to the local emergency room since she was having chest pain for the past several days. Overheard the DON speaking with Resident #2's spouse about how the facility does not have a physician that stays at the facility, but she would call the medical director if he wished ... ...At that point the DON stated that she would call EMS for Resident #2. Review of Resident #2's clinical record revealed no evidence of further documentation. In a telephone interview on 2/20/13 at 1:11 p.m. Resident #2's sister stated that Resident #2 began complaining of chest pain on Friday, 1/25/13 and the nurses gave her a shot to calm her down and didn't do anything for her chest pain. Finally on 1/31/13 my brother-in-law (Resident #2's spouse) insisted that the facility send her to the local emergency room . Review of Resident #2's clinical record from the local hospital "Patient Record" dated 1/31/13 documented the admitting [DIAGNOSES REDACTED]. Review of Resident #2's clinical record from the local hospital "EKG" dated 1/31/13 at 14:48 (2:48 p.m.) documented ".....ST and Marked T-wave abnormality, consider inferolateral ischemia ....prolonged QT .....abnormal EKG ...." Review of Resident #2's clinical record from the local hospital "History and Physical" dated 1/31/13 documented "......acute coronary syndrome; slight elevation of troponin and a very abnormal EKG indicating the patient most likely have acute coronary syndrome, most likely the patient had non-ST-elevation [MEDICAL CONDITION] infarction (MI -[MEDICAL CONDITION]) .....patient taken to cardiac catheterization lab ......" In an interview on 2/15/13 at 2:50 p.m. ADON stated that she felt that maybe the nurse didn't feel that Resident #2's chest pain was actually chest pain and that was the reason that the nurse gave her [MEDICATION NAME]. She acknowledged that a cardiac assessment was not documented. She stated that on 1/31/13 Resident #2's sister approached her about Resident #2's chest pain and that was when she called the medical director and obtained orders for a chest x-ray and EKG. She stated that she was told the reason Resident #2 was shipped to the local emergency room was because of an abnormal EKG. In an interview on 2/15/13 at 3:30 p.m. the DON stated that the facility should have called EMS to transport Resident #2 sooner due to Resident #2 requesting to go to the emergency room with chest pain. She stated that the normal practice at the facility is when a resident request to go to the local emergency room was to send them. She stated that with Resident #2's history of anxiety and with her [DIAGNOSES REDACTED]. In an interview on 2/15/13 at 4:10 p.m. LVN #2 stated that Resident #2 complained of pain in her breast area on 1/29/13 and requested to go to the local emergency room . She stated that she called the spouse to come in and speak with Resident #2 and called Resident #2's sister to come speak with her. She stated that Resident #2 kept calling out to go to the local emergency room . In an interview on 2/19/13 at 9:00 a.m. the DON stated that LVN #1 had given [MEDICATION NAME] to Resident #2 and that is was not in the LVN scope of practice to diagnose breast pain vs. chest pain. In an interview on 02/19/13 at 4:20 p.m., Resident #2 said, "I want to tell you about that horrible place. " She said she told staff she had chest pain, but no one did anything about it. Resident #2 said she told staff to take her to the hospital because of her chest pain. She said staff ignored her, and that the thought of the facility made her "skin crawl." Resident #2 said she prayed, and then she and her sister told the facility to take her to the hospital. Review of the facility's "Nursing Policies and Procedures - Physician Communication Grid" dated 9/11 documented for chest pain treatment is required within one hour. This also documented ".....these guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event. The above applies 24 hours a day, seven days a week ....." Review of the facility's "Nursing Policies and Procedures .....Physician Communication/Change in Condition" dated 9/11 documented "....the provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient/resident's condition ... ....complete assessment of the resident .....notify the physician of the change in medical condition ....the nurse will document all assessments and changes in the resident ' s condition in the medical record ...." On 2/19/13 at 9:56 a.m. the Administrator and DON were informed of Immediate Jeopardy Status. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "2/19/12 revised 2/20/13" received at 1:20 p.m. documented ".....On 1/1/13 an in-service was conducted on: - Change of Condition and Chest Pain - Hygiene - Resident request for Ambulance or ER services The Immediate Jeopardy was declared at 9:56 a.m. on 2/19/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education presented to the facility staff nurses by the Director of Nursing. - Resident Assessments - Detail Description and Demonstration of Head to Toe Assessment - Discussion of Normal and Abnormal Findings - Documentation of Assessments As of 10:00 a.m. on 2/20/13 all staff nurse have been re-educated. - Re-education for Licensed Nurses regarding importance of accurate assessment, accurate documentation, and reporting change in condition to physician and family. Nurses will perform timely assessments of residents with change of condition and document same. Residents with a known aspiration risk will be positioned with head of the bed elevated. This re-education was performed by the Director of Nursing/Assistant Directors of Nursing. Licensed Nurses who have not had the re-education will not be permitted to perform patient care without having the re-education. - Certified Nursing Assistants will be re-educated regarding the importance of recognizing and reporting changes in condition to the charge nurse. Re-education will include raising the head of the bed for residents who have been vomiting or are at risk of aspiration. Certified Nursing Assistants will be alerted to these new risk factors by the charge nurse as they occur. - The Director of Nursing/Assistant Director of Nursing has been monitoring the resident care areas, discussing any change of condition with the charge nurses throughout the work day and monitoring the 24 hour report for change of condition. Charge nurses have been instructed to call the DON with change of conditions to discuss actions taken and further actions needed. Charts of residents with change of condition during the 24 hour period are being reviewed to ensure that proper actions are being taken with change of condition, notifications were made, and any new orders have been implemented. This monitoring is being performed by the Director of Nursing/Assistant Directors of Nursing on a daily basis during the week and weekend RN on the weekend. - The resident's physician and Medical Director have been made aware of the alleged deficient practice and plans in place to correct. - The Performance Improvement Committee will review the above actions taken by the facility to correct the alleged deficient practice. - The Director of Nursing will report progress to the Performance Improvement Committee monthly for three months and then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions ....." In an interview on 02/20/13 at 8:10 a.m., LVN #5 said he received in-services 02/19/13 regarding change in condition and assessments. LVN #5 said that if a resident had a change in condition, nurses were to obtain vital signs, call the physician, and notify the family and DON. LVN #5 said all findings were to be documented, and that if a resident requested, staff were to send them to the hospital. In an interview on 02/20/13 at 8:16 a.m., LVN #6 said in-services were held 02/19/13 on assessment of residents and assessing changes in condition. LVN #6 said if a resident had a change in condition, nurses were to send them to the hospital instead of trying to figure out the problem. He said if a resident had a change in condition, he would notify the physician, family and DON, and document the events. In an interview on 02/20/13 at 8:40 a.m., LVN #3 said he received training 02/19/13 on full body assessments. He said he was told to get vital signs, notify the physician, and call the family and the DON. LVN #3 said if a resident had a change in condition, he would send them to the emergency room and document everything in the nurse's notes. In an interview on 2/20/13 at 2:15 p.m. LVN #4 stated that she had received in-service on 2/19/13 at 4:00 p.m. concerning the resident change of condition, complaints of chest pain, or requests to go to the emergency room . She stated that the DON stressed the importance of sending any resident who presents with any of the above to immediately send the resident to the local emergency room and to be sure and make detailed documentation. On 2/20/12 at 1:50 p.m. the Immediate Jeopardy was lowered to a scope and severity of actual harm that is not Immediate Jeopardy level at a pattern. CMS Form 672 dated 2/15/13 documented a census of 68.

Based on observation, interview and record review the facility failed to notify and consult with the physician and/or legal representative regarding significant changes in the physical/clinical status for one of eleven residents (Resident #2) reviewed for notification. The facility failed to notify and consult with Resident #2's physician when she began complaining of chest pain on 1/25/13 through 1/31/13. Resident #2 was given [MEDICATION NAME] (anti-psychotic) on 1/25/13 and [MEDICATION NAME] (heartburn) on 1/26/13 for complaints of chest pain. On 01/31/13 Resident #2 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy was identified on 2/19/13 at 9:56 a.m. While the Immediate Jeopardy was removed 2/20/12 at 1:50 p.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Sixty-eight residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #2's clinical record "Resident Admission Record" undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's clinical record "Admission Data Collection Tool" dated 1/23/13 documented under "...Active Diagnois in last 7 days....cancer with metastasis bone, brain, lung and liver....diabetes mellitus, asthma, left [PROCEDURE], [DIAGNOSES REDACTED] with a VP shunt and osteonecrosis of jaw....." Under the Nurse's Comment/Documentation documented "....received [AGE] year old female from local hospital via Geri-chair; alert unable to hear questions asked, requessts eraser board to write questions; continuously life eye lid to left eye to see nurse....Able to respond to questions, offered to feed regular food items, requested to wait until husband arrives, knows where she is, how many children she has, knows where pain is located; states repositioning my back and pain eases up.....requires extensive assistance for ADL's; incontinent of bowel and bladder......" Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/25/13 documented ".....at 1400 (2:00 p.m.) resident anxious, yelling out inconsolable, resident did take prn (as needed) [MEDICATION NAME] (anti-anxiety medication) but refused [MEDICATION NAME] (narcotic pain reliever) after three attempts ... ...at 1530 (3:30 p.m.) ....received fax order for [MEDICATION NAME] 2mg IM (intramuscular) every four hours as needed for agitation .....medication taken from e-kit (emergency box) and administered in left hip .... In an untimed entry for 1/25/13 documented " .....resident agitated, [MEDICATION NAME] 2mg given in left deltoid ....." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 10:15 a.m. documented " .....late entry for 1/26/13 at 1300 (1:00 p.m.) .... Family reports complaints of chest pain ... ...probably indigestion, [MEDICATION NAME] given at approximately 1315 (1:15 p.m.) .....no further chest pain ....." In a telephone interview on 2/19/13 at 8:15 a.m. LVN #1 stated that she had given [MEDICATION NAME] to Resident #2. She stated that her charge nurse, LVN #3 had told her to give [MEDICATION NAME] and did not tell her that Resident #2 was having chest pain and she did not do an assessment. In an interview on 2/19/13 at 8:35 a.m. LVN #3 verbally denied any knowledge of Resident #2 having chest pain. Review of Resident #2's clinical record "Nurse's Notes" dated 1/29/13 at 8:05 a.m. documented "......refuses to allow nurse to take vital signs ......complains of pain to left breast area ...." Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/30/13 documented "......resident yells repeatedly "help me, I need to get out of here" .....at 1600 (4:00 p.m.) "......resident family reports complaints of chest pain, resident denies chest pain ...." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 untimed documented "......late entry for 1/30/13 at 1600 (4:00 p.m.) resident's family reports complaints of chest pain ......" There was no evidence of documentation that nursing assessments or interventions were attempted or of physician notification. Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 9:40 a.m. documented "......resident's sister approached me in hall regarding resident complaint of chest pain for four days that hadn't been addressed to her knowledge .....explained that this was the first time {this nurse} was hearing of it, explained I'd call her physician and get an order at that point the sister informed me that she already called the physician and that the physician told her that the facility has a doctor to take care of that ....I explained to the sister that the physician is listed as primary doctor and that any orders regarding the resident would have to come from that physician .....I did explain that I would call the medical director and get an order for [REDACTED].the sister was very thankful ... ...spoke with medical director and received a verbal order for the chest x-ray and EKG ......" Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 1310 (1:10 p.m.) documented ".....resident complains of chest pain, new order for portable EKG and chest x-ray ....." Observation on 1/31/13 at approximately 1:00 p.m. to 1:15 p.m. overheard Resident #2's spouse in hallway yelling for Resident to go to the local emergency room since she was having chest pain for the past several days. Overheard the DON speaking with Resident #2's spouse about how the facility does not have a physician that stays at the facility, but she would call the medical director if he wished ... ...At that point the DON stated that she would call EMS for Resident #2. Review of Resident #2's clinical record revealed no evidence of further documentation. In a telephone interview on 2/20/13 at 1:11 p.m. Resident #2's sister stated that Resident #2 began complaining of chest pain on Friday, 1/25/13 and the nurses gave her a shot to calm her down and didn't do anything for her chest pain. Finally on 1/31/13 my brother-in-law (Resident #2's spouse) insisted that the facility send her to the local emergency room . Review of Resident #2's clinical record from the local hospital "Patient Record" dated 1/31/13 documented the admitting [DIAGNOSES REDACTED]. Review of Resident #2's clinical record from the local hospital "EKG" dated 1/31/13 at 14:48 (2:48 p.m.) documented ".....ST and Marked T-wave abnormality, consider inferolateral ischemia ....prolonged QT .....abnormal EKG ...." Review of Resident #2's clinical record from the local hospital "History and Physical" dated 1/31/13 documented "......acute coronary syndrome; slight elevation of troponin and a very abnormal EKG indicating the patient most likely have acute coronary syndrome, most likely the patient had non-ST-elevation [MEDICAL CONDITION] infarction (MI -[MEDICAL CONDITION]) .....patient taken to cardiac catheterization lab ......" In an interview on 2/15/13 at 2:50 p.m. ADON stated that she felt that maybe the nurse didn't feel that Resident #2's chest pain was actually chest pain and that was the reason that the nurse gave her [MEDICATION NAME]. She acknowledged that a cardiac assessment was not documented. She stated that on 1/31/13 Resident #2's sister approached her about Resident #2's chest pain and that was when she called the medical director and obtained orders for a chest x-ray and EKG. She stated that she was told the reason Resident #2 was shipped to the local emergency room was because of an abnormal EKG. In an interview on 2/15/13 at 3:30 p.m. the DON stated that the facility should have called EMS to transport Resident #2 sooner due to Resident #2 requesting to go to the emergency room with chest pain. She stated that the normal practice at the facility is when a resident request to go to the local emergency room was to send them. She stated that with Resident #2's history of anxiety and with her [DIAGNOSES REDACTED]. In an interview on 2/15/13 at 4:10 p.m. LVN #2 stated that Resident #2 complained of pain in her breast area on 1/29/13 and requested to go to the local emergency room . She stated that she called the spouse to come in and speak with Resident #2 and called Resident #2's sister to come speak with her. She stated that Resident #2 kept calling out to go to the local emergency room . In an interview on 2/19/13 at 9:00 a.m. the DON stated that LVN #1 had given [MEDICATION NAME] to Resident #2 and that is was not in the LVN scope of practice to diagnose breast pain vs. chest pain. In an interview on 02/19/13 at 4:20 p.m., Resident #2 said, "I want to tell you about that horrible place. " She said she told staff she had chest pain, but no one did anything about it. Resident #2 said she told staff to take her to the hospital because of her chest pain. She said staff ignored her, and that the thought of the facility made her "skin crawl." Resident #2 said she prayed, and then she and her sister told the facility to take her to the hospital. Review of the facility's "Nursing Policies and Procedures - Physician Communication Grid" dated 9/11 documented for chest pain treatment is required within one hour. This also documented ".....these guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event. The above applies 24 hours a day, seven days a week ....." Review of the facility's "Nursing Policies and Procedures .....Physician Communication/Change in Condition" dated 9/11 documented "....the provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient/resident's condition ... ....complete assessment of the resident .....notify the physician of the change in medical condition ....the nurse will document all assessments and changes in the resident ' s condition in the medical record ...." On 2/19/13 at 9:56 a.m. the Administrator and DON were informed of Immediate Jeopardy Status. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "2/19/12 revised 2/20/13" received at 1:20 p.m. documented ".....On 1/1/13 an in-service was conducted on: - Change of Condition and Chest Pain - Hygiene - Resident request for Ambulance or ER services The Immediate Jeopardy was declared at 9:56 a.m. on 2/19/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education presented to the facility staff nurses by the Director of Nursing. - Resident Assessments - Detail Description and Demonstration of Head to Toe Assessment - Discussion of Normal and Abnormal Findings - Documentation of Assessments As of 10:00 a.m. on 2/20/13 all staff nurse have been re-educated. - Re-education for Licensed Nurses regarding importance of accurate assessment, accurate documentation, and reporting change in condition to physician and family. Nurses will perform timely assessments of residents with change of condition and document same. Residents with a known aspiration risk will be positioned with head of the bed elevated. This re-education was performed by the Director of Nursing/Assistant Directors of Nursing. Licensed Nurses who have not had the re-education will not be permitted to perform patient care without having the re-education. - Certified Nursing Assistants will be re-educated regarding the importance of recognizing and reporting changes in condition to the charge nurse. Re-education will include raising the head of the bed for residents who have been vomiting or are at risk of aspiration. Certified Nursing Assistants will be alerted to these new risk factors by the charge nurse as they occur. - The Director of Nursing/Assistant Director of Nursing has been monitoring the resident care areas, discussing any change of condition with the charge nurses throughout the work day and monitoring the 24 hour report for change of condition. Charge nurses have been instructed to call the DON with change of conditions to discuss actions taken and further actions needed. Charts of residents with change of condition during the 24 hour period are being reviewed to ensure that proper actions are being taken with change of condition, notifications were made, and any new orders have been implemented. This monitoring is being performed by the Director of Nursing/Assistant Directors of Nursing on a daily basis during the week and weekend RN on the weekend. - The resident's physician and Medical Director have been made aware of the alleged deficient practice and plans in place to correct. - The Performance Improvement Committee will review the above actions taken by the facility to correct the alleged deficient practice. - The Director of Nursing will report progress to the Performance Improvement Committee monthly for three months and then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions ....." In an interview on 02/20/13 at 8:10 a.m., LVN #5 said he received in-services 02/19/13 regarding change in condition and assessments. LVN #5 said that if a resident had a change in condition, nurses were to obtain vital signs, call the physician, and notify the family and DON. LVN #5 said all findings were to be documented, and that if a resident requested, staff were to send them to the hospital. In an interview on 02/20/13 at 8:16 a.m., LVN #6 said in-services were held 02/19/13 on assessment of residents and assessing changes in condition. LVN #6 said if a resident had a change in condition, nurses were to send them to the hospital instead of trying to figure out the problem. He said if a resident had a change in condition, he would notify the physician, family and DON, and document the events. In an interview on 02/20/13 at 8:40 a.m., LVN #3 said he received training 02/19/13 on full body assessments. He said he was told to get vital signs, notify the physician, and call the family and the DON. LVN #3 said if a resident had a change in condition, he would send them to the emergency room and document everything in the nurse's notes. In an interview on 2/20/13 at 2:15 p.m. LVN #4 stated that she had received in-service on 2/19/13 at 4:00 p.m. concerning the resident change of condition, complaints of chest pain, or requests to go to the emergency room . She stated that the DON stressed the importance of sending any resident who presents with any of the above to immediately send the resident to the local emergency room and to be sure and make detailed documentation. On 2/20/12 at 1:50 p.m. the Immediate Jeopardy was lowered to a scope and severity of actual harm that is not Immediate Jeopardy level at a pattern. CMS Form 672 dated 2/15/13 documented a census of 68.

Based on observation, interview and record review the facility failed to notify and consult with the physician and/or legal representative regarding significan changes in the physical/clinical status for one of 11 residents (Resident #2). The facility nursing staff failed to assess Resident #2, consult her physician, or honor her requests to go to the hospital when she began complaining of chest pain on 1/25/13 through 1/31/13. Resident #2 was given [MEDICATION NAME] (anti-psychotic) on 1/25/13 and [MEDICATION NAME] (heartburn) on 1/26/13 for complaints of chest pain. On 01/31/13 Resident #2 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy was identified on 2/19/13 at 9:56 a.m. While the Immediate Jeopardy was removed 2/20/12 at 1:50 p.m. the facility remained out of compliance at a scope of pattern and a severity level of actual harm because the facility had not had time to evaluate its own action plan for effectiveness. Sixty-eight residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: <http://info.sos.state.tx.us/pls/pub/readact$est.TacPage?sl=R&app=9&p_rloc=&p_tloc=&p_ploc=&pg-1&ti=22&ch=217&rl=11> The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. - ".....Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: - know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local lawys, rules or regulations affecting the nurse's current area of nursing practice - know the rationale for and the affects of medications and treatments and shall correctly administer the same; - Acurately and completely report and document; - the client's status including signs and symptoms - nursing care rendered - administration of medications and treatments - client response(s) and - contacts with other health care team members concering significant events regarding client's status - Institute appropriate nursing interventions that might be required to stablize a client's condition and/or prevent complications - Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; Review of Resident #2's clinical record "Resident Admission Record" undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's clinical record "Admission Data Collection Tool" dated 1/23/13 documented under "...Active Diagnois in last 7 days....cancer with metastasis bone, brain, lung and liver....diabetes mellitus, asthma, left [PROCEDURE], [DIAGNOSES REDACTED] with a VP shunt and osteonecrosis of jaw....." Under the Nurse's Comment/Documentation documented "....received [AGE] year old female from local hospital via Geri-chair; alert unable to hear questions asked, requessts eraser board to write questions; continuously life eye lid to left eye to see nurse....Able to respond to questions, offered to feed regular food items, requested to wait until husband arrives, knows where she is, how many children she has, knows where pain is located; states repositioning my back and pain eases up.....requires extensive assistance for ADL's; incontinent of bowel and bladder......" Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/25/13 documented ".....at 1400 (2:00 p.m.) resident anxious, yelling out inconsolable, resident did take prn (as needed) [MEDICATION NAME] (anti-anxiety medication) but refused [MEDICATION NAME] (narcotic pain reliever) after three attempts ... ...at 1530 (3:30 p.m.) ....received fax order for [MEDICATION NAME] 2mg IM (intramuscular) every four hours as needed for agitation .....medication taken from e-kit (emergency box) and administered in left hip .... In an untimed entry for 1/25/13 documented " .....resident agitated, [MEDICATION NAME] 2mg given in left deltoid ....." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 10:15 a.m. documented " .....late entry for 1/26/13 at 1300 (1:00 p.m.) .... Family reports complaints of chest pain ... ...probably indigestion, [MEDICATION NAME] given at approximately 1315 (1:15 p.m.) .....no further chest pain ....." In a telephone interview on 2/19/13 at 8:15 a.m. LVN #1 stated that she had given [MEDICATION NAME] to Resident #2. She stated that her charge nurse, LVN #3 had told her to give [MEDICATION NAME] and did not tell her that Resident #2 was having chest pain and she did not do an assessment. In an interview on 2/19/13 at 8:35 a.m. LVN #3 verbally denied any knowledge of Resident #2 having chest pain. Review of Resident #2's clinical record "Nurse's Notes" dated 1/29/13 at 8:05 a.m. documented "......refuses to allow nurse to take vital signs ......complains of pain to left breast area ...." Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/30/13 documented "......resident yells repeatedly "help me, I need to get out of here" .....at 1600 (4:00 p.m.) "......resident family reports complaints of chest pain, resident denies chest pain ...." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 untimed documented "......late entry for 1/30/13 at 1600 (4:00 p.m.) resident's family reports complaints of chest pain ......" There was no evidence of documentation that nursing assessments or interventions were attempted. Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 9:40 a.m. documented "......resident's sister approached me in hall regarding resident complaint of chest pain for four days that hadn't been addressed to her knowledge .....explained that this was the first time {this nurse} was hearing of it, explained I'd call her physician and get an order at that point the sister informed me that she already called the physician and that the physician told her that the facility has a doctor to take care of that ....I explained to the sister that the physician is listed as primary doctor and that any orders regarding the resident would have to come from that physician .....I did explain that I would call the medical director and get an order for [REDACTED].the sister was very thankful ... ...spoke with medical director and received a verbal order for the chest x-ray and EKG ......" Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 1310 (1:10 p.m.) documented ".....resident complains of chest pain, new order for portable EKG and chest x-ray ....." Observation on 1/31/13 at approximately 1:00 p.m. to 1:15 p.m. overheard Resident #2's spouse in hallway yelling for Resident to go to the local emergency room since she was having chest pain for the past several days. Overheard the DON speaking with Resident #2's spouse about how the facility does not have a physician that stays at the facility, but she would call the medical director if he wished ... ...At that point the DON stated that she would call EMS for Resident #2. Review of Resident #2's clinical record revealed no evidence of further documentation. In a telephone interview on 2/20/13 at 1:11 p.m. Resident #2's sister stated that Resident #2 began complaining of chest pain on Friday, 1/25/13 and the nurses gave her a shot to calm her down and didn't do anything for her chest pain. Finally on 1/31/13 my brother-in-law (Resident #2's spouse) insisted that the facility send her to the local emergency room . Review of Resident #2's clinical record from the local hospital "Patient Record" dated 1/31/13 documented the admitting [DIAGNOSES REDACTED]. Review of Resident #2's clinical record from the local hospital "EKG" dated 1/31/13 at 14:48 (2:48 p.m.) documented ".....ST and Marked T-wave abnormality, consider inferolateral ischemia ....prolonged QT .....abnormal EKG ...." Review of Resident #2's clinical record from the local hospital "History and Physical" dated 1/31/13 documented "......acute coronary syndrome; slight elevation of troponin and a very abnormal EKG indicating the patient most likely have acute coronary syndrome, most likely the patient had non-ST-elevation [MEDICAL CONDITION] infarction (MI -[MEDICAL CONDITION]) .....patient taken to cardiac catheterization lab ......" In an interview on 2/15/13 at 2:50 p.m. ADON stated that she felt that maybe the nurse didn't feel that Resident #2's chest pain was actually chest pain and that was the reason that the nurse gave her [MEDICATION NAME]. She acknowledged that a cardiac assessment was not documented. She stated that on 1/31/13 Resident #2's sister approached her about Resident #2's chest pain and that was when she called the medical director and obtained orders for a chest x-ray and EKG. She stated that she was told the reason Resident #2 was shipped to the local emergency room was because of an abnormal EKG. In an interview on 2/15/13 at 3:30 p.m. the DON stated that the facility should have called EMS to transport Resident #2 sooner due to Resident #2 requesting to go to the emergency room with chest pain. She stated that the normal practice at the facility is when a resident request to go to the local emergency room was to send them. She stated that with Resident #2's history of anxiety and with her [DIAGNOSES REDACTED]. In an interview on 2/15/13 at 4:10 p.m. LVN #2 stated that Resident #2 complained of pain in her breast area on 1/29/13 and requested to go to the local emergency room . She stated that she called the spouse to come in and speak with Resident #2 and called Resident #2's sister to come speak with her. She stated that Resident #2 kept calling out to go to the local emergency room . In an interview on 2/19/13 at 9:00 a.m. the DON stated that LVN #1 had given [MEDICATION NAME] to Resident #2 and that is was not in the LVN scope of practice to diagnose breast pain vs. chest pain. In an interview on 02/19/13 at 4:20 p.m., Resident #2 said, "I want to tell you about that horrible place. " She said she told staff she had chest pain, but no one did anything about it. Resident #2 said she told staff to take her to the hospital because of her chest pain. She said staff ignored her, and that the thought of the facility made her "skin crawl." Resident #2 said she prayed, and then she and her sister told the facility to take her to the hospital. Review of the facility's "Nursing Policies and Procedures - Physician Communication Grid" dated 9/11 documented for chest pain treatment is required within one hour. This also documented ".....these guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event. The above applies 24 hours a day, seven days a week ....." Review of the facility's "Nursing Policies and Procedures .....Physician Communication/Change in Condition" dated 9/11 documented "....the provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient/resident's condition ... ....complete assessment of the resident .....notify the physician of the change in medical condition ....the nurse will document all assessments and changes in the resident ' s condition in the medical record ...." On 2/19/13 at 9:56 a.m. the Administrator and DON were informed of Immediate Jeopardy Status. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "2/19/12 revised 2/20/13" received at 1:20 p.m. documented ".....On 1/1/13 an in-service was conducted on: - Change of Condition and Chest Pain - Hygiene - Resident request for Ambulance or ER services The Immediate Jeopardy was declared at 9:56 a.m. on 2/19/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education presented to the facility staff nurses by the Director of Nursing. - Resident Assessments - Detail Description and Demonstration of Head to Toe Assessment - Discussion of Normal and Abnormal Findings - Documentation of Assessments As of 10:00 a.m. on 2/20/13 all staff nurse have been re-educated. - Re-education for Licensed Nurses regarding importance of accurate assessment, accurate documentation, and reporting change in condition to physician and family. Nurses will perform timely assessments of residents with change of condition and document same. Residents with a known aspiration risk will be positioned with head of the bed elevated. This re-education was performed by the Director of Nursing/Assistant Directors of Nursing. Licensed Nurses who have not had the re-education will not be permitted to perform patient care without having the re-education. - Certified Nursing Assistants will be re-educated regarding the importance of recognizing and reporting changes in condition to the charge nurse. Re-education will include raising the head of the bed for residents who have been vomiting or are at risk of aspiration. Certified Nursing Assistants will be alerted to these new risk factors by the charge nurse as they occur. - The Director of Nursing/Assistant Director of Nursing has been monitoring the resident care areas, discussing any change of condition with the charge nurses throughout the work day and monitoring the 24 hour report for change of condition. Charge nurses have been instructed to call the DON with change of conditions to discuss actions taken and further actions needed. Charts of residents with change of condition during the 24 hour period are being reviewed to ensure that proper actions are being taken with change of condition, notifications were made, and any new orders have been implemented. This monitoring is being performed by the Director of Nursing/Assistant Directors of Nursing on a daily basis during the week and weekend RN on the weekend. - The resident's physician and Medical Director have been made aware of the alleged deficient practice and plans in place to correct. - The Performance Improvement Committee will review the above actions taken by the facility to correct the alleged deficient practice. - The Director of Nursing will report progress to the Performance Improvement Committee monthly for three months and then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions ....." In an interview on 02/20/13 at 8:10 a.m., LVN #5 said he received in-services 02/19/13 regarding change in condition and assessments. LVN #5 said that if a resident had a change in condition, nurses were to obtain vital signs, call the physician, and notify the family and DON. LVN #5 said all findings were to be documented, and that if a resident requested, staff were to send them to the hospital. In an interview on 02/20/13 at 8:16 a.m., LVN #6 said in-services were held 02/19/13 on assessment of residents and assessing changes in condition. LVN #6 said if a resident had a change in condition, nurses were to send them to the hospital instead of trying to figure out the problem. He said if a resident had a change in condition, he would notify the physician, family and DON, and document the events. In an interview on 02/20/13 at 8:40 a.m., LVN #3 said he received training 02/19/13 on full body assessments. He said he was told to get vital signs, notify the physician, and call the family and the DON. LVN #3 said if a resident had a change in condition, he would send them to the emergency room and document everything in the nurse's notes. In an interview on 2/20/13 at 2:15 p.m. LVN #4 stated that she had received in-service on 2/19/13 at 4:00 p.m. concerning the resident change of condition, complaints of chest pain, or requests to go to the emergency room . She stated that the DON stressed the importance of sending any resident who presents with any of the above to immediately send the resident to the local emergency room and to be sure and make detailed documentation. On 2/20/12 at 1:50 p.m. the Immediate Jeopardy was lowered to a scope and severity of actual harm that is not Immediate Jeopardy level at a pattern. CMS Form 672 dated 2/15/13 documented a census of 68.

483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to notify and consult with the physician and/or legal representative regarding significant changes in the physical/clinical status for one of 11 residents (Resident #2). The facility failed to assess Resident #2, consult her physician, or honor her requests to go to the hospital when she began complaining of chest pain on 1/25/13 through 1/31/13. Resident #2 was given [MEDICATION NAME] (anti-psychotic) on 1/25/13 and [MEDICATION NAME] (heartburn) on 1/26/13 for complaints of chest pain. On 01/31/13 Resident #2 was admitted to the hospital with [REDACTED]. Sixty-eight residents could be placed at risk for an untreated life threatening medical event if the deficient practice continued. Findings included: Review of Resident #2's clinical record "Resident Admission Record" undated documented she was a [AGE] year old female originally admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's clinical record "Admission Data Collection Tool" dated 1/23/13 documented under "...Active Diagnois in last 7 days....cancer with metastasis bone, brain, lung and liver....diabetes mellitus, asthma, left [PROCEDURE], [DIAGNOSES REDACTED] with a VP shunt and osteonecrosis of jaw....." Under the Nurse's Comment/Documentation documented "....received [AGE] year old female from local hospital via Geri-chair; alert unable to hear questions asked, requessts eraser board to write questions; continuously life eye lid to left eye to see nurse....Able to respond to questions, offered to feed regular food items, requested to wait until husband arrives, knows where she is, how many children she has, knows where pain is located; states repositioning my back and pain eases up.....requires extensive assistance for ADL's; incontinent of bowel and bladder......" Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/25/13 documented ".....at 1400 (2:00 p.m.) resident anxious, yelling out inconsolable, resident did take prn (as needed) [MEDICATION NAME] (anti-anxiety medication) but refused [MEDICATION NAME] (narcotic pain reliever) after three attempts ... ...at 1530 (3:30 p.m.) ....received fax order for [MEDICATION NAME] 2mg IM (intramuscular) every four hours as needed for agitation .....medication taken from e-kit (emergency box) and administered in left hip .... In an untimed entry for 1/25/13 documented " .....resident agitated, [MEDICATION NAME] 2mg given in left yelids), metastatic breast [MEDICAL CONDITION], history of brain metastases and prior [MEDICAL CONDITION] therapy, [DIAGNOSES REDACTED], deltoid ....." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 10:15 a.m. documented " .....late entry for 1/26/13 at 1300 (1:00 p.m.) .... Family reports complaints of chest pain ... ...probably indigestion, [MEDICATION NAME] given at approximately 1315 (1:15 p.m.) .....no further chest pain ....." In a telephone interview on 2/19/13 at 8:15 a.m. LVN #1 stated that she had given [MEDICATION NAME] to Resident #2. She stated that her charge nurse, LVN #3 had told her to give [MEDICATION NAME] and did not tell her that Resident #2 was having chest pain and she did not do an assessment. In an interview on 2/19/13 at 8:35 a.m. LVN #3 verbally denied any knowledge of Resident #2 having chest pain. Review of Resident #2's clinical record "Nurse's Notes" dated 1/29/13 at 8:05 a.m. documented "......refuses to allow nurse to take vital signs ......complains of pain to left breast area ...." Review of Resident #2's clinical record "Daily Skilled Nurse's Note" dated 1/30/13 documented "......resident yells repeatedly "help me, I need to get out of here" .....at 1600 (4:00 p.m.) "......resident family reports complaints of chest pain, resident denies chest pain ...." Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 untimed documented "......late entry for 1/30/13 at 1600 (4:00 p.m.) resident's family reports complaints of chest pain ......" There was no evidence of documentation that nursing assessments or interventions were attempted. Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 9:40 a.m. documented "......resident's sister approached me in hall regarding resident complaint of chest pain for four days that hadn't been addressed to her knowledge .....explained that this was the first time {this nurse} was hearing of it, explained I'd call her physician and get an order at that point the sister informed me that she already called the physician and that the physician told her that the facility has a doctor to take care of that ....I explained to the sister that the physician is listed as primary doctor and that any orders regarding the resident would have to come from that physician .....I did explain that I would call the medical director and get an order for [REDACTED].the sister was very thankful ... ...spoke with medical director and received a verbal order for the chest x-ray and EKG ......" Review of Resident #2's clinical record "Nurse's Notes" dated 1/31/13 at 1310 (1:10 p.m.) documented ".....resident complains of chest pain, new order for portable EKG and chest x-ray ....." Observation on 1/31/13 at approximately 1:00p.m. to 1:15 p.m. overheard Resident #2's spouse in hallway yelling for Resident to go to the local emergency room since she was having chest pain for the past several days. Overheard the DON speaking with Resident #2's spouse about how the facility does not have a physician that stays at the facility, but she would call the medical director if he wished ... ...At that point the DON stated that she would call EMS for Resident #2. Review of Resident #2's clinical record revealed no evidence of further documentation. In a telephone interview on 2/20/13 at 1:11 p.m. Resident #2's sister stated that Resident #2 began complaining of chest pain on Friday, 1/25/13 and the nurses gave her a shot to calm her down and didn't do anything for her chest pain. Finally on 1/31/13 my brother-in-law (Resident #2's spouse) insisted that the facility send her to the local emergency room . Review of Resident #2's clinical record from the local hospital "Patient Record" dated 1/31/13 documented the admitting [DIAGNOSES REDACTED]..ST and Marked T-wave abnormality, consider inferolateral ischemia ....prolonged QT .....abnormal EKG ...." Review of Resident #2's clinical record from the local hospital "History and Physical" dated 1/31/13 documented "......acute coronary syndrome; slight elevation of troponin and a very abnormal EKG indicating the patient most likely have acute coronary syndrome, most likely the patient had non-ST-elevation [MEDICAL CONDITION] infarction (MI -[MEDICAL CONDITION]) .....patient taken to cardiac catheterization lab ......" In an interview on 2/15/13 at 2:50 p.m. ADON stated that she felt that maybe the nurse didn't feel that Resident #2's chest pain was actually chest pain and that was the reason that the nurse gave her [MEDICATION NAME]. She acknowledged that a cardiac assessment was not documented. She stated that on 1/31/13 Resident #2's sister approached her about Resident #2's chest pain and that was when she called the medical director and obtained orders for a chest x-ray and EKG. She stated that she was told the reason Resident #2 was shipped to the local emergency room was because of an abnormal EKG. In an interview on 2/15/13 at 3:30 p.m. the DON stated that the facility should have called EMS to transport Resident #2 sooner due to Resident #2 requesting to go to the emergency room with chest pain. She stated that the normal practice at the facility is when a resident request to go to the local emergency room was to send them. She stated that with Resident #2's history of anxietyand with her [DIAGNOSES REDACTED]. In an interview on 2/15/13 at 4:10 p.m. LVN #2 stated that Resident #2 complained of pain in her breast area on 1/29/13 and requested to go to the local emergency room . She stated that she called the spouse to come in and speak with Resident #2 and called Resident #2's sister to come speak with her. She stated that Resident #2 kept calling out to go to the local emergency room . In an interview on 2/19/13 at 9:00 a.m. the DON stated that LVN #1 had given [MEDICATION NAME] to Resident #2 and that is was not in the LVN scope of practice to diagnose breast pain vs. chest pain. In an interview on 02/19/13 at 4:20 p.m., Resident #2 said, "I want to tell you about that horrible place. " She said she told staff she had chest pain, but no one did anything about it. Resident #2 said she told staff to take her to the hospital because of her chest pain. She said staff ignored her, and that the thought of the facility made her "skin crawl." Resident #2 said she prayed, and then she and her sister told the facility to take her to the hospital. Review of the facility's "Nursing Policies and Procedures - Physician Communication Grid"dated 9/11 documented for chest pain treatment is required within one hour. This also documented ".....these guidelines are not intended to substitute for good nursing judgment. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event. The above applies 24 hours a day, seven days a week ....." Review of the facility's "Nursing Policies and Procedures .....Physician Communication/Change in Condition" dated 9/11 documented "....the provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient/resident's condition ... ....complete assessment of the resident .....notify the physician of the change in medical condition ....the nurse will document all assessments and changes in the resident ' s condition in the medical record ...." On 2/19/13 at 9:56 a.m. the Administrator and DON were informed of Immediate Jeopardy Status. Review of the facility's "Abatement Plan to Remove Immediate Jeopardy" dated "2/19/12 revised 2/20/13" received at 1:20 p.m. documented ".....On 1/1/13 an in-service was conducted on: -Change of Condition and Chest Pain-Hygiene -Resident request for Ambulance or ER services The Immediate Jeopardy was declared at 9:56 a.m. on 2/19/13. Immediate re-education was written and staff was called in for the education. Below is the content of the re-education presented to the facility staff nurses by the Director of Nursing. -Resident Assessments -Detail Description and Demonstration of Head to Toe Assessment -Discussion of Normal and Abnormal Findings -Documentation of Assessments As of 10:00 a.m. on 2/20/13 all staff nurse have been re-educated. -Re-education for Licensed Nurses regarding importance of accurate assessment, accurate documentation, and reporting change in condition to physician and family. Nurses will perform timely assessments of residents with change of condition and document same. Residents with a known aspiration risk will be positioned with head of the bed elevated. This re-education was performed by the Director of Nursing/Assistant Directors of Nursing. Licensed Nurses who have not had the re-education will not be permitted to perform patient care without having the re-education. -Certified Nursing Assistants will be re-educated regarding the importance of recognizing and reporting changes in condition to the charge nurse. Re-education will include raising the head of the bed for residents who have been vomiting or are at risk of aspiration. Certified Nursing Assistants will be alerted to these new risk factors by the charge nurse as they occur. -The Director of Nursing/Assistant Director of Nursing has been monitoring the resident care areas, discussing any change of condition with the charge nurses throughout the work day and monitoring the 24 hour report for change of condition. Charge nurses have been instructed to call the DON with change of conditions to discuss actions taken and further actions needed. Charts of residents with change of condition during the 24 hour period are being reviewed to ensure that proper actions are being taken with change of condition, notifications were made, and any new orders have been implemented. This monitoring is being performed by the Director of Nursing/Assistant Directors of Nursing on a daily basis during the week and weekend RN on the weekend. -The resident's physician and Medical Director have been made aware of the alleged deficient practice and plans in place to correct. -The Performance Improvement Committee will review the above actions taken by the facility to correct the alleged deficient practice. -The Director of Nursing will report progress to the Performance Improvement Committeemonthly for three months and then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions ....." In an interview on 02/20/13 at 8:10 a.m., LVN #5 said he received in-services 02/19/13 regarding change in condition and assessments. LVN #5 said that if a resident had a change in condition, nurses were to obtain vital signs, call the physician, and notify the family and DON. LVN #5 said all findings were to be documented, and that if a resident requested, staff were to send them to the hospital. In an interview on 02/20/13 at 8:16 a.m., LVN #6 said in-services were held 02/19/13 on assessment of residents and assessing changes in condition. LVN #6 said if a resident had a change in condition, nurses were to send them to the hospital instead of trying to figure out the problem. He said if a resident had a change in condition, he would notify the physician, family and DON, and document the events. In an interview on 02/20/13 at 8:40 a.m., LVN #3 said he received training 02/19/13 on full body assessments. He said he was told to get vital signs, notify the physician, and call the family and the DON. LVN #3 said if a resident had a change in condition, he would send them to the emergency room and document everything in the nurse's notes. In an interview on 2/20/13 at 2:15 p.m. LVN #4 stated that she had received in-service on2/19/13 at 4:00 p.m. concerning the resident change of condition, complaints of chest pain, or requests to go to the emergency room . She stated that the DON stressed the importance of sending any resident who presents with any of the above to immediately send the resident to the local emergency room and to be sure and make detailed documentation. On 2/20/12 at 1:50 p.m. the Immediate Jeopardy was lowered to a scope and severity of actual harm that is not Immediate Jeopardy level at a pattern. CMS Form 672 dated 2/15/13 documented a census of 68.

Based on observation, interview and record review the facility failed to provide care and services to maintain the highest practicable well-being for one of 18 residents (Resident #15) reviewed for quality of care. The facility failed to recognize, assess, and intervene timely when Resident #15 moaned, yelled, and screamed for four days before her doctor was notified. A physical assessment was not completed by nursing staff. Resident #15 experienced a fecal impaction and perforated bowel that resulted in emergency surgery with a permanent [MEDICAL CONDITION] placement. An Immediate Jeopardy was identified on 12/19/12 at 1:18 p.m. The Immediate Jeopardy was removed on 12/19/12 at 4:57 p.m. The facility remained out of compliance at widespread of actual harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. These failures could affect any of the 85 residents in the facility at risk for constipation. Failure to identify and assess residents for constipation could lead to fecal impaction, bowel perforation, and death. Findings include: 1. In an interview on 12/03/12 at 6:45 p.m., during initial tour, CNA A identified Resident #15 was not in the facility. She stated Resident #15 went to the hospital, and had emergency surgery because her bowels ruptured from being "real impacted". CNA A said Resident #15 was still in ICU and had a new [MEDICAL CONDITION]. Record review of Resident #15's Resident Admission Record dated 08/30/12 revealed she was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's Annual MDS assessment dated [DATE] revealed she had unclear speech, was sometimes understood, and sometimes understood others. Resident #15 scored a 2 on her BIMS Assessment (score of 0-7 indicates severe cognitive impairment). Resident #15 required extensive assistance of two or more people for toileting and personal hygiene. Resident #15 was always incontinent of bowel. Record review of Resident #15's Care Plan dated 11/29/12 revealed she was incontinent and required extensive assistance with activities of daily living including incontinent care. There was no documentation of new or increased behaviors such as yelling, screaming, combative, fidgety, or unable to make comfortable noted. In an interview on 12/06/12 at 2:30 p.m. CNA D said she provided care for Resident #15 from 11/29/12 at 10:00 p.m. to 11/30/12 at 6:00 a.m. CNA D said Resident #15 yelled out and was having diarrhea all night. CNA D said Resident #15 was restless, complaining of abdominal pain and unable to console the entire shift. CNA D said she reported information regarding Resident #15 to the charge nurse numerous times. CNA D clarified, at least three times. CNA D described Resident #15's stools as liquid and watery. She said as soon as she would provide incontinent care, Resident #15 would have diarrhea again. The nurse that provided care for Resident #15 from 11/29/12 at 6:00 p.m. to 11/30/12 at 6:00 a.m. was not available for interview. In an interview on 12/06/12 at 11:00 a.m. LVN A stated she was the charge nurse responsible for the care for Resident #15 on 11/30/12 for the 6am-6pm shift. LVN A said she was informed in report Resident #15 was having diarrhea and a stool specimen had been collected. LVN A said Resident #15 was pale and clammy, not eating, having nausea and vomiting, liquid watery stools, and running a low grade temperature. LVN A said she called the primary care physician's office around 10:00 a.m., obtained and order for [MEDICATION NAME] (medication for nausea), and was told the Physician B would come to the facility to see Resident #15 later that day. LVN A stated she had been off work for days prior, but could tell something was different with Resident #15 as early as breakfast. LVN A said Resident #15 was screaming, combative, fidgety, inconsolable, and complaining of abdominal pain. LVN A said she observed Resident #15 sticking her whole hand in her mouth and down her throat. LVN A said it appeared Resident #15 was attempting to induce vomiting. LVN A said she could not assess Resident #15's abdomen because of the yelling and combativeness. LVN A said she reported Resident #15's condition to LVN C. LVN A said she contacted Resident #15's physician at least twice and possibly three times on 11/30/12 to report the changes in her condition. LVN A said Physician B came to the facility that afternoon, assessed Resident #15 and gave orders to send her to the emergency room . Record review of Resident #15's Nurse's Notes revealed the following: 11/29/12- 9:10 a.m. - resident yelling loudly, unbuckles her safety belt in where is trying to slide herself out of chair. Unable to redirect. Food and fluids offered. Resident agitated. ABH (topical medication mixture of [MEDICATION NAME] and [MEDICATION NAME] used for behaviors) gel topically 7:45 p.m. (Late entry on 11/30/12 at 2:00 a.m.) - resident complained of diarrhea requested medicine. Call placed to on call physician new order received to obtain stool specimen to check for [DIAGNOSES REDACTED] ([MEDICAL CONDITION]) (an infection in the bowel causing severe diarrhea) 11:00 p.m. - resident hollering loudly, repositioned multiple times and will quiet down for two to three minutes and then holler out again. Noise level and lighting level changed. Unable to redirect, Resident agitated. 11:30 p.m. - medicated with ABH gel topically 1:00 a.m. (11/30/12) - continues to holler out loudly and is repositioned every 15 to 30 minutes. Food and fluid offered. Lighting and noise levels changed with minimal effectiveness 11/30/12- 2:00 a.m. - continues to holler out "I want to scoot over" frequent repositioning with minimal effect in decreased behavior 3:00 a.m. - stool specimen obtained and sent to lab 10:30 a.m. - doctor's office notified of new orders received from on call physician, doctor's office stated Dr. (Physician B) would be out to see resident. Resident has had an increase in behaviors, yelling, cussing, and throwing objects at staff. Resident complained of abdominal pain and having bouts of nausea and vomiting. Observed resident putting fingers down her throat to induce vomiting. New order for [MEDICATION NAME] 25 milligrams IM (intramuscular), to be given every six hours as needed for pain. Administered at this time in right hip. 11:00 a.m. - continues to have nausea, vomiting and abdominal pain. Dr. (Physician B) notified to come to the facility. Results of stool negative for [DIAGNOSES REDACTED], Dr. (Physician B) notified 3:00 p.m. - Dr. (Physician B) on the unit and assessed resident, new orders to transfer resident to the emergency room 3:30 p.m. - ambulance on the unit and transferred at this time In an interview on 12/06/12 at 11:15 a.m. LVN C stated Resident #15 had screamed for three days prior to 11/30/12. LVN C said the Social Worker had mentioned in a morning meeting approximately one week prior that Resident #15's abdomen was hard. LVN C described Resident #15's color to be grey on 11/30/12. LVN C said she told the DON that Resident #15 did not look good. LVN C said she accompanied Physician B while he assessed Resident #15. LVN C said she encouraged Physician B to send Resident #15 to the hospital. In an interview on 12/06/12 at 11:35 a.m. the Social Worker described Resident #15 as mentally challenged. She said Resident #15 was able to communicate, but only in simple terms. She said Resident # 15 was not able to use a call light and would yell out to get the staff's attention. The Social Worker said Resident # 15 started sporadically screaming more frequently. The Social Worker said these screams sounded different. The Social Worker explained, these screams sounded like pain. The Social Worker said she went to Resident #15's room on the evening of 11/26/12 to respond to Resident #15 screaming. The Social Worker said she felt of Resident #15's abdomen and it felt "tight". The Social Worker said she reported it to the nurse on duty and mentioned it in the morning meeting with all department heads the next day. The Social Worker said the DON was present in that meeting. Record review of Resident #15's Vitals Report revealed the following: 11/25/12 at 12:17 a.m., Bowel Movement-none 11/25/12 at 2:41 a.m., Bowel Movement- none 11/25/12 at 4:48 a.m., Bowel Movement- small, incontinent, loose, brown 11/26/12 at 5:27 a.m., bowel Movement- small 11/27/12 at 3:35 a.m., Bowel Movement- none 11/28/12 at 8:10 p.m., Bowel Movement- medium, incontinent, liquid 11/28/12 at 8:10 p.m., Bowel Movement- medium, incontinent, liquid 11/28/12 at 8:11 p.m., Bowel Movement- medium, incontinent, liquid 11/28/12 at 8:11 p.m., Bowel Movement- medium, incontinent, liquid 11/28/12 at 8:57 p.m., Bowel Movement- large 11/29/12 at 8:28 p.m., Bowel Movement, large 11/30/12 at 12:52 a.m., Bowel Movement, large, incontinent, loose, liquid, brown 11/30/12 at 3:14 a.m., Bowel Movement- large, incontinent, loose, liquid, brown, foul odor Record review of Resident #15's Social Worker Notes dated 11/28/12 revealed "...during Administrative Team Stand Up meeting Resident could be heard screaming ..." Record review of Resident #15's Physician's Progress Notes date 11/30/12 revealed a face to face visit with Physician B. Physician B documented "...unusual behavior, yelling, sticking fingers into mouth, diaphoretic (sweaty), fight or flight appearance, 99 degrees Fahrenheit, tachy ([MEDICAL CONDITION]) 100 ...ext (extremities) cool, wet,[MEDICAL CONDITION] ...difficult to manage at NH (nursing home) send to (Hospital name) ER (emergency room ) ..." Record review of Resident #15's Emergency Physician Record dated 11/30/12 revealed she was combative for 3-4 days, appeared to be in severe distress, severe pain with decreased bowel sounds to the abdomen, non-verbal, screams, admit condition guarded. Observation on 12/06/12 at 9:15 a.m., revealed Resident #15 was in ICU (Intensive Care Unit) at the local hospital. Resident #15 was connected to numerous IV lines and monitors. She was not interviewable. Resident #15 had facial grimacing and audible moaning was noted. In an interview on 12/06/12 at 9:20 a.m. Resident #15's Surgeon stated she assumed care of Resident #15 on 11/30/12. The Surgeon stated Resident #15 presented through the emergency room with severe abdominal pain and free air in her belly. The Surgeon explained free air does not belong in the abdomen and could indicate a rupture of some kind. The Surgeon said she attempted to assess Resident #15, but when she placed her stethoscope on the abdomen Resident #15 screamed in pain. She said Resident #15 was [MEDICAL CONDITION] (fast heart rate) and unable to obtain a blood pressure. The Surgeon stated with the information she had at the time, she declared the situation an emergency and directed the hospital to send Resident #15 to surgery immediately without consent. The Surgeon said once Resident #15 was sedated and prepped for surgery she could feel a large, hard mass in her left lower abdomen. She said she thought she was going to find a [MEDICAL CONDITION] tumor. The Surgeon said as soon as she opened Resident #15's abdomen she had an immediate return of fecal matter. She said Resident #15's abdomen was completely full of several large, hard balls of stool. She described them as "cantaloupe" sized. She said after removing all the fecal matter from Resident #15's abdomen, she had to place a [MEDICAL CONDITION] (surgical opening in the abdomen for stool to pass from the body). The Surgeon said she could see the area the colon perforated and described it to be about two inches long. The Surgeon said Resident #15 had experienced several complications since surgery, and would be lucky to survive. Record review of Resident #15's Hospital Progress Note dated 11/30/12 written by the Surgeon revealed "...patient is a [AGE] year old, white female resident at (facility name) who has been hollering for the last four days. Today she developed nausea/vomiting and came to the ER. Patient is nonverbal. She screams when you press on her abdomen ...positive for nausea/vomiting ...unable to obtain blood pressure ...unable to assess bowel sounds patient screams when you touch her belly ...free air ...to operating room to do exploratory laparotomy. We have attempted to contact her caregiver (Guardian) ...they have not returned our phone calls ...this patient is [MEDICAL CONDITION] with low blood pressure. I'm declaring this procedure an emergency and proceeding to the operating room ..." Record review of Resident #15's Radiology Report dated 11/30/12 revealed "...air- fluid level layering along the right lateral abdomen on the left lateral decubitus view. This represents free intraperitoneal air which can be due to bowel perforation ..." Record review of Resident #15's Surgical Pathology Report dated 12/04/12 revealed "...container #1 received in [MEDICATION NAME] labeled with the patient's name and stool from peritoneal cavity and rectum is a 15 x 15 x 7 centimeter aggregate of tan-brown to firm fecal material. No soft tissue is present ..." In an interview on 12/06/12 at 12:30 p.m. the DON described Resident #15 as mentally retarded. She said Resident #15 had become more anxious lately, was screaming a lot and undoing the seatbelt on her wheelchair for two to three days. The DON said Resident #15 was in the hospital with a perforated bowel, status [REDACTED].#15 had experienced an increase in behaviors over the few days prior to 11/30/12. The DON described the behaviors as yelling, screaming, and unable to get comfortable. She said Resident #15 would request to be assisted to bed and within a few minutes request to be assisted to her wheelchair. The DON could not explain why there was no documentation of the increased behaviors in Resident #15's medical record. When ask about the events that occurred on 11/30/12 the DON said, sometime after breakfast, LVN A reported Resident #15 was vomiting and trying to put her hand down her throat and that the physician was notified. The DON stated she went to Resident #15's room and could hear her screaming as she approached. She said she assisted her to bed at the Resident's request. She said Resident #15 was yelling and screaming and described her as fidgety, and unable to get comfortable. The DON said she did not perform a physical assessment on Resident #15. She said she thought the increased yelling and screaming were because of behaviors and did not further assess for any physical signs or symptoms of distress. The DON said she was unaware Resident #15 had experienced loose, watery stools for several days prior to 11/30/12. The DON said the facility conducted a Care Plan meeting on 11/29/12 for Resident #15. The DON stated Resident #15's increased yelling was not discussed. The DON said Resident #15 was at risk for constipation related to the use of narcotic pain medicine, decreased mobility, and dependent on staff to obtain liquids. The DON reviewed Resident #15's Care Plan and confirmed there was no plan of care to prevent constipation. The DON stated Resident #15 fell through the cracks of their systems. She said Resident #15 suffered harm due to neglect for the facility. The DON stated she should have performed a full assessment when Resident #15 experienced a change in behaviors. The DON admitted responsibility for missing the signs presented to indicate Resident #15 had suffered a fecal impaction resulting in a bowel perforation. The DON stated any of the 85 residents in the facility could be at risk for fecal impaction. Record review of "Preventing, assessing, and managing constipation in older adults " accessed on 12/13/12 at <http://journals.lww.com/nursing/Fulltext/2012/ /Preventing,_assessing,_and_managing_constipation.13.aspx> revealed: "...Constipation, one of the five most commonly diagnosed conditions in outpatient visits, is a significant and potentially costly problem because of the expense of over-the counter medications, healthcare provider office visits, ED and related hospital admissions, specialty referrals, and associated surgical procedures ... Age-related changes affecting the gastrointestinal (GI) system, including decreased peristalsis and altered acid secretion, are often overlooked. Constipation reduces patients' quality of life. Depression, anxiety, decreased social activities, and pain can significantly undermine their physical and mental well-being ... Pay careful attention to medications that are known to cause constipation as an adverse reaction, such as opioids ... perform a physical assessment. First inspect the abdomen, then auscultate for bowel sounds, percuss for dullness, and palpate for masses. Constipation often causes the abdomen to become distended and tender ... Bowel regularity is affected by diet, medication use, disease, and habit. Depending on the cause, treatment for constipation may include nonpharmacologic and pharmacologic measures. Standard treatments include increasing fiber and fluid intake, exercising, avoiding constipation causing drugs ... Complications of constipation include hemorrhoids, anal fissures, rectal prolapse, intestinal obstruction, and fecal impaction. Fecal impaction occurs when hard stool packs the intestine or rectum so tightly that stool can't be expelled... Because fecal impaction can manifest as [MEDICAL CONDITION] in older patients, be sure to assess a patient with a change in mental status for this problem and to identify and prevent any potential causes of constipation, including a review of medications that can aggravate the condition ... Nurses are in an ideal position to identify patients at risk for constipation and to assess for signs and symptoms. Obtain the patient's health history, noting risk factors such as inadequate fluid intake, decreased mobility, and comorbid conditions. Assess the patient's diet, including fiber intake. Perform medication reconciliation, including the use of over-the-counter medications and herbal supplements. Look for anything that may contribute to constipation ... Ask about the patient's oral health; changes in appetite; patterns of bowel movements; consistency, color, and size of the stool; seepage of stool; degree of straining during bowel movements; ignoring the urge to defecate; and nausea, vomiting, or other GI complaints ..." The facility's Plan of Removal submitted for the removal of the IJ submitted on 12/19/12 at 4:20 p.m. and accepted 12/19/12 at 4:57 p.m. reflected the following: "Abatement Plan to Remove Immediate Jeopardy ... Re-education for Licensed Nurses and Certified Nursing Assistants regarding importance of accurate recording of bowel movements, monitoring and reporting absence or change in bowel movements, i.e., diarrhea or watery stools. This re-education was performed by the Director of Nursing/Assistant Directors of Nursing and was completed on 12/18/12. Licensed Nurses and Certified Nursing Assistants who have not had the re-education will not be permitted to perform patient care without having the re-education. An audit was performed to determine residents at risk for constipation. This audit was reviewed by the Director of Nursing/Assistant Directors of Nursing. Residents at risk for constipation attending physicians were notified for further orders. Care plans were updated to reflect current treatment for identified residents. Care plans will be updated with any further resident specific interventions related to constipation. The Registered Dietician reviewed those residents at risk for dietary interventions to assist with avoiding constipation. Recommendations made by the Registered Dietician were followed up by the Director of Nursing/Assistant Director of Nursing and physicians were contacted to review recommendations and obtain orders as needed. This was on or before 12/18/12. The Pharmacy Consultant reviewed those residents at risk for constipation caused as a side effect from medications to assist with avoiding constipation. Recommendations made by the Pharmacy Consultant were followed up by the Director of Nursing/Assistant Directors of Nursing and physicians were contacted to review recommendations and obtain orders as needed. This was completed on or before 12/18/12. Monitoring reports from Point of Care were reviewed to determine those residents not having bowel movements. This monitoring has been performed by the Director of Nursing/Assistant Directors of Nursing on a daily basis since 12/07/12 and will be an ongoing process to monitor resident bowel movement. The Director of Nursing/Assistant Directors of Nursing is monitoring the 24 hour report for change of condition related to bowel management. This monitoring has been performed by the Director of Nursing/Assistant Directors of Nursing on a daily basis since 12/07/12 and will be ongoing process to monitor bowel movement. The resident ' s physician and Medical Director have been made aware of the alleged deficient practice and plans in place to correct. Facility Director of Nursing met with the physician on Friday 12/14/12 to discuss the resident care provided prior to hospitalization . The December Performance Improvement Committee reviewed the above actions taken by the facility to correct the alleged deficient practice. The Director of Nursing will report progress to the Performance Improvement Committee monthly x 3, then quarterly until compliance has been achieved. Any areas of concern will be addressed at the time of discovery for further interventions." (Signed by the Administrator 12/19/12) The survey team confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: In an interview with LVN D on 12/19/12 at 1:20 p.m., the LVN said that residents were being monitored daily for constipation. He said that two or three in-services had been conducted with instructions that if a resident appeared on the daily list of residents who had not had bowel movements in three days the nurses were to listen for bowel sounds, follow-up, encourage fluids and give a laxative if needed. In an interview on 12/19/2012 at 2:40 p.m., Nurse J said that if she is told that a resident is reporting constipation or if there are signs of constipation first she will ask the patient(if alert) when their last bowel movement occurred. Nurse G then said that she would assess the resident's abdomen by checking for bowel sounds, any palpable masses, abdominal distention or abdominal tenderness. Nurse G said that she would then manually check the resident to see if there was any stool in the rectum. She then said that she would check the physician's orders [REDACTED]. Nurse G said that she would give an ordered laxative and if the resident did not have anything ordered for constipation that she would contact the resident ' s physician and obtain an order. Nurse G said that then she would monitor for a bowel movement and put that a laxative was given to the resident on the 24 hour report. Nurse J said that if the resident was still unable to have a bowel movement after all ordered medications had been given that she would call the physician back for further orders. Nurse J said that if the resident was reporting abdominal pain that she would send them to the emergency room for evaluation. Nurse J reported several recent in- services in regards to the importance of bowel movements, documenting bowel movements and how to perform an abdominal assessment. In an interview on 12/20/12 at 8: 45 a.m., CNA H said that when she is recording a bowel movement in the Kiosk that she includes the size of the bowel movement, whether the resident was continent or incontinent, color, consistency and characteristics of the bowel movement. CNA H said that if a resident reports being constipated, is having a hard time having a bowel movement or if noticed anything unusual like blood in the resident's bowel movement she informs the nurse on duty. In an interview on 12/20/12 at 8:55 a.m., CNA F said that the facility had had recent in-service regarding documenting bowel movement. She said that they were told that the documentation is very important. CNA F said that when recording a resident's bowel movement in the Kiosk that the documentation is to include the size of the bowel movement, the color, consistency of the stool, whether the resident was continent or incontinent and characteristics of the stool. CNA F said that she reports to the nurse anything out of the ordinary. She said that she reports if the resident is constipated, is needing assistance with having a bowel movement or bloody stools. In an interview on 12/20/12 at 8:55 a.m., CNA I said that when she records a resident's bowel movements in the Kiosk that she includes the size, color, consistency and characteristics. CNA I said that she would report any hard or bloody stools to the nurse. CNA I said that she would tell the nurse if she knew that a resident had not had a bowel movement in a couple of days. CNA I said that they recently had an in-service over the importance of documenting a residents bowel movement and on letting the nurse know of any constipation issues or changes with the residents. In an interview on 12/20/12 at 9:25 a.m., CNA J said she had been in-serviced recently on changes to the KIOSK. CNA J said staff were now required to enter the color, consistency and characteristics of bowel movements. She said she knew there was a list of residents who had not had a bowel movement in three days, and that the nurses gave these residents a suppository or something. In an interview on 12/20/12 at 9:33 a.m., CNA K said she had recently received an in-service on the KIOSK and how to put in bowel movements to onclude color, consistency, size and characteristics, and whether the resident was continent or incontinent. CNA K said she was informed by the DON to report any bowel problems to the charge nurse. CNA K said the DON also told her to report to the DON if the charge nurses did not give residents a medication for any bowel problems. In an interview with the Dietary Manager (DM) on 12/20/12 at 9:40 a.m., she confirmed the Dieticians recommendations. She stated that more oatmeal had been added to the breakfast menu as well as some high fiber cereals. The DM also said that prune juice had been added to the snack carts and that nurses were requesting it more for residents. The DM also said that she was offering more whole wheat bread with meals, that beans were being substituted for some potato entries on the menus. The DM confirmed that water and juices were offered with snacks and that water, tea and coffee were available to residents twenty-four hours a day. While the IJ was lowered on 12/19/12 at 4:57 p.m., the facility remained out of compliance at a Severity level of Actual Harm and Scope of Widespread that is not IJ because the facility was continuing to monitor the plan of removal for effectiveness. Record review of CMS 672 dated 12/03/12 revealed a facility census of 85.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Residents #13) of seven residents reviewed for neglect. The facility failed to provide resuscitative measures to Resident #13 when he suffered a respiratory arrest as evidenced by: 1) Resident #13 was noted to have stopped breathing by a CNA B on [DATE] at 4:00 p.m. CNA B reported to LVN B that Resident #13 was not breathing. LVN B told CNA B she had just given Resident #13 a breathing treatment and that Resident #13 was fine. LVN B did not check on Resident #13. CNA B went back to Resident #13's room. Resident #13 was still not breathing. CNA B again told LVN B that Resident #13 was not breathing. LVN B told CNA B that she had just seen Resident #13 and that Resident #13 was fine. CNA B then informed CMA A that Resident #13 was not breathing. CMA A went to Resident #13's room to check on him and a code blue was called. Two minutes after Resident #13 stopped breathing, CPR was started. EMS (911) was called, and EMS arrived at 4:10 p.m. and took over CPR. Resident #13 was pronounced deceased at 4:36 p.m. by EMS. The findings include: Review of the facility's policy, "Abuse, Neglect and Misappropriation of Property" dated ,[DATE] revealed, "The facility's leadership prohibits neglect, mental or physical abuse, including, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds...The facility's leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident...Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness..." Review of the facility's "Position Description, Licensed Practical Nurse" dated [DATE] and revised ,[DATE] revealed, "...Initiates emergency support measures (i.e., CPR...)..." Review of the facility's policy, "Resuscitation of Patients/Residents With and Without Automatic External Defibrillation (AED)" dated ,[DATE] revealed, "...1. Appropriate staff members in the immediate area immediately respond and: A. Calls or designates a person to call 911 or locally appropriate emergency number. B. Assists with Basic Life Support...2. Initiate CPR with or without AED..." This failure could affect any of the 33 residents in the facility with "Full Code" Directives. This was determined to be past non-compliance Immediate Jeopardy on [DATE] at 2:10 p.m. due to the facility having taken some measures by incorporating the occurrence into their QAA, providing in-services that included mock code blue's, and terminating LVN B. This failure could affect any of the 33 residents in the facility that request to be resuscitated if a cardiac or respiratory arrest occurred. Review of Resident #13's "Physician order [REDACTED]. Resident #13 had been admitted to the hospital [DATE] for Respiratory Distress and [MEDICAL CONDITION] and re-admitted to the facility on [DATE]. Resident #13's [DIAGNOSES REDACTED]. In an interview on [DATE] at 10:40 a.m., the DON said the facility did an investigation of the incident after Resident #13 experienced a code blue and expired. The DON said all staff were given in-services on the code blue process and reporting any changes in a resident's condition. The DON said LVN B told her she had not handled Resident #13's code blue correctly. The DON said LVN B said she had not been in a code blue in a long time, and could only think to call 911. LVN B was suspended during the investigation. LVN B was then terminated. Two telephone messages left for LVN B by the surveyor on [DATE] were not returned. Review of the facility's typed investigation reports revealed the following: 1. "On [DATE] (CNA B) went into (Resident #13's) room to do a round and check to see if he needed anything. When (CNA B) entered the room (Resident #13) stated to him "Thank you, (CNA B). You are the best CNA I have ever had. I am ready to go. I'm going home." (Resident #13) then laid back on the bed and (CNA B) noticed his skin turning whiter. (CNA B) walked closer to see if he was ok and noticed (Resident #13) was not breathing. (CNA B) then went to the charge nurse (LVN B) and stated, "(resident's name) Resident #13 is not breathing can you come check on him? He's not breathing for real." (LVN B) replied, "I just gave him his breathing treatment he is fine." (CNA B) then went back to (Resident #13's) room to check on him to make sure. (Resident #13) was not breathing. (CNA B) then went back to (LVN B) and told her, "(Resident #13) is not breathing." (LVN B) stated again, "I just saw him he is fine." (CNA B) then turned to (CMA A) the med aide and asked her to come check because (Resident #13) was not breathing. (LVN B) then went to the room and looked at him (Resident #13). (LVN B) came out of the room and told them to call a code." (Signed by CNA B and the DON.) 2. "On [DATE] around my afternoon med pass 4:00 p.m.-4:30 p.m. (CNA B) came down the hall and approached me about (Resident #13's) condition. (CNA B) reported that he (Resident #13) was not breathing. I then acknowledged to (LVN B) about the situation. (LVN B) replied I was just in there giving him a breathing treatment he's (Resident #13) fine. I looked at (CNA B), locked my med cart, went down there with him. (Resident #13) was in the bed flat with his eyes open, gray color, not breathing. I came back to (LVN B) told her the same, (Resident #13) was not breathing needed her stat. (CNA C was there with us and said the same, (Resident #13) was not breathing, no oxygen, no breathing treatment mask. (LVN B) looked at us and replied the same, I just gave him an [MEDICATION NAME] treatment and the two doctors (wound care) just came out of there- a few minutes later we asked (LVN B) please come down and (LVN B) did. (LVN B) then came out of the room terrified and replied call a code. I did and (LVN B) said get everyone in here. Then we did and the DON, ADON's Administrator, CNA's and me went to help lower (Resident #13) to the floor to start CPR from the nurse (LVN D). We continued to attempt to revive (Resident #13) and someone called 911. (Signed by CMA A and the DON) 3. " I called (LVN B) into the administrator's office after receiving report that (CNA B) had told (LVN B) twice that a resident was not breathing and (LVN B) did not respond to (CNA B's) request for help. (LVN B) was tearful and stated to me that (LVN B) knew (LVN B) had made a mistake. I asked (LVN B) what (LVN B) was doing and what (LVN B) was thinking that prevented (LVN B) from responding. (LVN B) stated (LVN B) had a lot of things going on and (LVN B) had been in the resident's room a little while earlier to administer a breathing treatment and (Resident #13) was fine then. (LVN B) kept saying, "I don' t know what I was thinking." I told (LVN B) there was not another situation that could have been going on that would have been more important.(LVN B) stated to me that the first time (CNA B) came to her, (LVN B) finished what (LVN B) was doing and them went down the hall to put (LVN B's) stuff down. Then when (LVN B) was heading down to the room I was already there with 3 or 4 other nurses. (LVN B) stated (LVN B) felt overwhelmed today because (LVN B) had to work in the dining room early this morning. (LVN B) stated (LVN B) stated at the time of the occurrence (LVN B) had a lot of paperwork to do and had another resident crying and displaying anxious behaviors. I again stated to (LVN B) that none of those situations were more important than responding to a report that a resident was not breathing. (LVN B) continued to be tearful and state that (LVN B) knew (LVN B) did not handle the situation correctly. After the conversation I talked with the administrator about the report and (LVN B's) comments about (LVN B's) actions and we made the decision to suspend (LVN B) pending investigation. During the suspension conversation (LVN B) continued to state (LVN B) had used poor judgment and did not know what (LVN B) was thinking. (LVN B) acknowledged again that (LVN B) had told the (CNA B) that (LVN B) had just been there and could not understand why (LVN B) did not just go check." (Typed and signed by the DON.) 4. "Interview of (LVN B) regarding incident [DATE]: (LVN B) states (CNA B) came to her when (LVN B) was down the hallway close to E17. (LVN B) was getting ready to do an accu-check (a blood drop sample taken to check the glucose level). (CNA B) came to (LVN B) and said, "(Resident #13) can't breathe." (LVN B) responded to him, "I just started a breathing treatment on (Resident #13). I'll go back and check on him in a few minutes." Then (LVN B) went in and performed the accu-check on the other resident. (CNA B) then came back to (LVN B) as (LVN B) was exiting the other resident's room and stated, (Resident #13's) not breathing." (LVN B) stated, "OK." (LVN B) pushed the med cart down the hall to the nurse's station and then went to (Resident #13's) room. (LVN B) went to (Resident #13) and pulled the breathing treatment mask off (Resident #13). (LVN B) checked for respirations and pulse. (LVN B) told one of the CNA's, not sure which one to get (LVN B) some help because (LVN B) could not find a pulse or respirations. (LVN B) went out into the hallway and told (CMA A) "We have a code." (CMA A) stated, "I know I called it." Then (LVN B) left the room to call 911. While (LVN B) was calling 911 (LVN B) saw the other nurses running down the hallway to the room." (Signed by the DON and LVN B.) In an interview on [DATE] at 1:32 p.m., LVN D said he did chest compressions on Resident #13 on [DATE] while the DON used the ambu bag (A bag valve mask, abbreviated to BVM and sometimes known by the proprietary name Ambu bag, is a hand-held device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately. The device is a normal part of a resucitation kit for trained professionals (<http://en.wikipedia.org/wiki) for respirations. LVN D said Resident #13 did not respond to CPR. LVN D said the emergency medical service arrived about 4:10 p.m. and took over CPR. LVN D said the EMS pronounced Resident #13 dead at the facility. 6.In a telephone interview on [DATE] at 4:30 p.m., CNA B said he checked on Resident #13 and Resident #13 said he was leaving. CNA B said Resident #13 stopped breathing. CNA B said he called out for LVN B to come, but LVN B said she had just come out of Resident #13's room and that he (Resident 313) was fine. CNA B said he checked Resident #13 again and told LVN B again that Resident #13 was not breathing. LVN B again told CNA B that Resident #13 was fine. CNA B said he then told CMA A (that Resident #13 was not breathing) and CMA A checked on Resident #13 and called a code blue. CNA B said LVN B went to Resident #13's room later. The facility took the following action to correct the non-compliance on [DATE]: ? " Immediately suspended the nurse pending investigation. ? Full investigation initiated. ? Re-education with staff regarding: ? Code blue process ? Licensed nurses re-educated regarding: ? Responding to reports of change in condition by staff, families and/or visitors ? Caring for residents with respiratory conditions ? Met with QA internal team during daily morning meeting and discussed the events of the code and corrections made thus far. ? Program Director, also physician of record, was notified via telephone of events of the code and corrections made thus far. ? P.I. meeting scheduled for [DATE]. ? Daily quiz different staff members to assess their understanding of the re-education, identify needs for further education, and provide said education as needed. ? Standards for code blue drills to be set by QA committee on [DATE]. Will be at least quarterly or more often as directed be the QA committee. ? Results of code blue drills will be discussed with the safety committee and reported to the QA committee. In-services were reviewed for staff re-education on code blue, respiratory issues, notifying appropriate staff, communicating changes in condition and responding to information provided. Interviews with staff revealed they had been in-serviced and were aware of measures to take in the event of a code blue or respiratory distress. The facility's "Advanced Directives and Code Status Report" dated [DATE] revealed 33 residents with "Full Code" directives.

Based on observation, interview and record review the facility failed to follow their policy to prevent neglect of ,[DATE] Residents (Resident # 13) reveiwed for neglect. The facility failed to recognize, assess, and intervene timely as evidenced by: a) Resident #13stopped breathing and was not provided CPR as per his wishes. Resident #13 was noted to have stopped breathing by a CNA B on [DATE] at 4:00 p.m. CNA B reported to LVN B that Resident #13 was not breathing. LVN B told CNA B she had just given Resident #13 a breathing treatment and that Resident #13 was fine. LVN B did not check on Resident #13. CNA B went back to Resident #13's room. Resident #13 was still not breathing. CNA B again told LVN B that Resident #13 was not breathing. LVN B told CNA B that she had just seen Resident #13 and that Resident #13 was fine. CNA B then informed CMA A that Resident #13 was not breathing. CMA A went to Resident #13's room to check on him and a code blue (Code Blue is generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory arrest or [MEDICAL CONDITION].) was called. Two minutes after Resident #13 stopped breathing, CPR was started. EMS (911) was called, and EMS arrived at 4:10 p.m. and took over CPR. Resident #13 was pronounced deceased at 4:36 p.m. by EMS. This was determined to be past non-compliance Immediate Jeopardy on [DATE] at 2:10 p.m. due to the facility having taken measures by incorporating the occurrence into their QAA, providing in-services that included mock code blue's, and terminating LVN B. This failure could affect any of the 33 residents in the facility that request to be resuscitated if a cardiac or respiratory arrest occurred. The findings include: Review of Resident #13's "Physician order [REDACTED]. Resident #13's "Physician order [REDACTED]. Resident #13 had been admitted to the hospital [DATE] for Respiratory Distress and [MEDICAL CONDITION] and re-admitted to the facility on [DATE]. Resident #13's [DIAGNOSES REDACTED]. In an interview on [DATE] at 10:40 a.m., the DON said the facility did an investigation of the incident after Resident #13 experienced a code blue and expired. The DON said all staff were given in-services on the code blue process and reporting any changes in a resident's condition. The DON said LVN B told her she had not handled Resident #13's code blue correctly. The DON said LVN B said she had not been in a code blue in a long time, and could only think to call 911. Two telephone messages left for LVN B by the surveyor on [DATE] were not returned. Review of the facility's typed investigation reports revealed the following: 1. "On [DATE] (CNA B) went into (Resident #13's) room to do a round and check to see if he needed anything. When (CNA B) entered the room (Resident #13) stated to him "Thank you, (CNA B). You are the best CNA I have ever had. I am ready to go. I'm going home." (Resident #13) then laid back on the bed and (CNA B) noticed his skin turning whiter. (CNA B) walked closer to see if he was ok and noticed (Resident #13) was not breathing. (CNA B) then went to the charge nurse (LVN B) and stated, "(resident's name) Resident #13 is not breathing can you come check on him? He's not breathing for real." (LVN B) replied, "I just gave him his breathing treatment he is fine." (CNA B) then went back to (Resident #13's) room to check on him to make sure. (Resident #13) was not breathing. (CNA B) then went back to (LVN B) and told her, "(Resident #13) is not breathing." (LVN B) stated again, "I just saw him he is fine." (CNA B) then turned to (CMA A) the med aide and asked her to come check because (Resident #13) was not breathing. (LVN B) then went to the room and looked at him (Resident #13). (LVN B) came out of the room and told them to call a code." (Signed by CNA B and the DON) 2. "On [DATE] around my afternoon med pass 4:00 p.m.-4:30 p.m. (CNA B) came down the hall and approached me about (Resident #13's) condition. (CNA B) reported that he (Resident #13) was not breathing. I then acknowledged to (LVN B) about the situation. (LVN B) replied I was just in there giving him a breathing treatment he's (Resident #13) fine. I looked at (CNA B), locked my med cart, went down there with him. (Resident #13) was in the bed flat with his eyes open, gray color, not breathing. I came back to (LVN B) told her the same, (Resident #13) was not breathing needed her stat. (CNA C) was there with us and said the same, (Resident #13) was not breathing, no oxygen, no breathing treatment mask. (LVN B) looked at us and replied the same, I just gave him an [MEDICATION NAME] treatment and the two doctors (wound care) just came out of there- a few minutes later we asked (LVN B) please come down and (LVN B) did. (LVN B) then came out of the room terrified and replied call a code. I did and (LVN B) said get everyone in here. Then we did and the DON, ADON's Administrator, CNA's and me went to help lower (Resident #13) to the floor to start CPR from the nurse (LVN D). We continued to attempt to revive (Resident #13) and someone called 911.( Signed by CMA A and the DON) 3. "I called (LVN B) into the administrator's office after receiving report that (CNA B) had told (LVN B) twice that a resident was not breathing and (LVN B) did not respond to (CNA B's) request for help. (LVN B) was tearful and stated to me that (LVN B) knew (LVN B) had made a mistake. I asked (LVN B) what (LVN B) was doing and what (LVN B) was thinking that prevented (LVN B) from responding. (LVN B) stated (LVN B) had a lot of things going on and (LVN B) had been in the resident's room a little while earlier to administer a breathing treatment and (Resident #13) was fine then. (LVN B) kept saying, "I don't know what I was thinking." I told (LVN B) there was not another situation that could have been going on that would have been more important.(LVN B) stated to me that the first time (CNA B) came to her, (LVN B) finished what (LVN B) was doing and them went down the hall to put (LVN B's) stuff down. Then when (LVN B) was heading down to the room I was already there with 3 or 4 other nurses. (LVN B) stated (LVN B) felt overwhelmed today because (LVN B) had to work in the dining room early this morning. (LVN B) stated (LVN B) stated at the time of the occurrence (LVN B) had a lot of paperwork to do and had another resident crying and displaying anxious behaviors. I again stated to (LVN B) that none of those situations were more important than responding to a report that a resident was not breathing. (LVN B) continued to be tearful and state that (LVN B) knew (LVN B) did not handle the situation correctly. After the conversation I talked with the administrator about the report and (LVN B's) comments about (LVN B's) actions and we made the decision to suspend (LVN B) pending investigation. During the suspension conversation (LVN B) continued to state (LVN B) had used poor judgment and did not know what (LVN B) was thinking. (LVN B) acknowledged again that (LVN B) had told the (CNA B) that (LVN B) had just been there and could not understand why (LVN B) did not just go check" (Typed and signed by the DON.) 4. "Interview of (LVN B) regarding incident [DATE]: (LVN B) states (CNA B) came to her when (LVN B) was down the hallway close to E17. (LVN B) was getting ready to do an accu-check (a blood drop sample taken to check the glucose level). (CNA B) came to (LVN B) and said, "(Resident #13) can't breathe." (LVN B) responded to him, "I just started a breathing treatment on (Resident #13). I'll go back and check on him in a few minutes." Then (LVN B) went in and performed the accu-check on the other resident. (CNA B) then came back to (LVN B) as (LVN B) was exiting the other resident's room and stated, (Resident #13's) not breathing." (LVN B) stated, "OK." (LVN B) pushed the med cart down the hall to the nurse's station and then went to (Resident #13's) room. (LVN B) went to (Resident #13) and pulled the breathing treatment mask off (Resident #13). (LVN B) checked for respirations and pulse. (LVN B) told one of the CNA's, not sure which one to get (LVN B) some help because (LVN B) could not find a pulse or respirations. (LVN B) went out into the hallway and told (CMA A) "We have a code." (CMA A) stated, "I know I called it." Then (LVN B) left the room to call 911. While (LVN B) was calling 911 (LVN B) saw the other nurses running down the hallway to the room." (Signed by the DON and LVN B.) 5. In an interview on [DATE] at 1:32 p.m., LVN D said he did chest compressions on Resident #13 on [DATE] while the DON used the ambu bag (A bag valve mask, abbreviated to BVM and sometimes known by the proprietary name Ambu bag, is a hand-held device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately. The device is a normal part of a resucitation kit for trained professionals (<http://en.wikipedia.org/wiki) for respirations. LVN D said Resident #13 did not respond to CPR. LVN D said the emergency medical service arrived about 4:10 p.m. and took over CPR. LVN D said the EMS pronounced Resident #13 dead at the facility. 6.In a telephone interview on [DATE] at 4:30 p.m., CNA B said he checked on Resident #13 and Resident #13 said he was leaving. CNA B said Resident #13 stopped breathing. CNA B said he called out for LVN B to come, but LVN B said she had just come out of Resident #13's room and that he (Resident 313) was fine. CNA B said he checked Resident 313 again and told LVN B again that Resident #13 was not breathing. LVN B again told CNA B that Resident #13 was fine. CNA B said he then told CMA A (that Resident #13 was not breathing) and CMA A checked on Resident #13 and called a code blue. CNA B said LVN B went to Resident #13's room later. The facility took the following action to correct the non-compliance on [DATE]: ? " Immediately suspended the nurse pending investigation. ? Full investigation initiated. ? Re-education with staff regarding: ? Code blue process ? Licensed nurses re-educated regarding: ? Responding to reports of change in condition by staff, families and/or visitors ? Caring for residents with respiratory conditions ? Met with QA internal team during daily morning meeting and discussed the events of the code and corrections made thus far. ? Program Director, also physician of record, was notified via telephone of events of the code and corrections made thus far. ? P.I. meeting scheduled for [DATE]. ? Daily quiz different staff members to assess their understanding of the re-education, identify needs for further education, and provide said education as needed. ? Standards for code blue drills to be set by QA committee on [DATE]. Will be at least quarterly or more often as directed be the QA committee. ? Results of code blue drills will be discussed with the safety committee and reported to the QA committee. In-services were reviewed for staff re-education on code blue, respiratory issues, notifying appropriate staff, communicating changes in condition and responding to information provided. Interviews with staff revealed they had been in-serviced and were aware of measures to take in the event of a code blue or respiratory distress. Review of the facility's policy, "Abuse, Neglect and Misappropriation of Property" dated ,[DATE] revealed, "...Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness..." Review of the facility's "Position Description, Licensed Practical Nurse" dated [DATE] and revised ,[DATE] revealed, "...Initiates emergency support measures (i.e., CPR...)..." Review of the facility's policy, "Resucitation of Patients/Residents With and Without Automatic External Defibrillation (AED)" dated ,[DATE] revealed, "...1. Appropriate staff members in the immediate area immediately respond and: A. Calls or designates a person to call 911 or locally appropriate emergency number. B. Assists with Basic Life Support...2. Initiate CPR with or without AED..." Review of a fax sent by the facility [DATE] revealed LVN B did not have a CPR card in her personnel file. The facility's "Advanced Directives and Code Status Report" dated [DATE] revealed 33 residents with "Full Code" directives.

Based on interview, observation and record review it was determined the facility failed to ensure 2 residents (Residents #18, and #23) of 7 residents reviewed for social services received appropriate treatment and services. The facility failed to ensure: 1. Assess Resident #18 when she had a mental status change causing her to be admitted to a psychiatric facility for a psychotic break; 2. Resident #23 received intervention and services for behaviors affecting others to include Resident #18. These failures placed 25 residents identified with behavior symptoms placing them at risk for displaying behaviors negatively affecting themselves or others. Findings included: 1. Record review of Resident #18's "Resident Admission Record", dated 10/20/2011, revealed a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of "Telephone Orders" for Resident #18 revealed the following: "... 5/23/12... Send to inpatient Psychiatric Hospital for tx (treatment) if ok "with" PCP (primary care physician)..." "... 6/25/12... Send back to in-patient psych d/t (due to) [MEDICAL CONDITION] and homicidall (sic) statements..." In a confidential interview on 12/04/12 at 11:37 a.m. it was revealed that Resident #18 was discharged from the facility after she had a psychosocial change. It was revealed that she was having verbal altercations with another resident, and as a result was transferred to a psychiatric hospital for inpatient services. The interviewee stated that resident experienced her psychosocial change due to the other resident. In a confidential interview on 12/06/12 at 3:17 p.m. it was revealed that Resident #18 and Resident #23 had been having verbal altercations. It was revealed that Resident #18 requested something be done to stop Resident #23 from bothering her. The interviewee stated that the facility failed to address Resident #23's behavior. It was revealed that Resident #23 created a hostile environment for residents and that in the opinion of the interviewee Resident #23 created an anxious environment causing other residents to fear her. Record review of a document entitled "Minimum Data Set (MDS)" dated 09/28/11 regarding Resident #18 revealed the following: "... Type of Assessment... Admission assessment..." "... Brief Interview for Mental Status... Summary Score 14... add scores for questions... (00-15) {indicates the highest score is 15 and lowest is 00}..." "... Section D... Mood... D0200. Resident Mood Interview... 0 {indicating no symptom presence} for little interest or please in doing things, feeling down, depress, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling bad about yourself - or that you are a failure or have let yourself or your family down, thoughts that you would be better off dead, or of hurting yourself in some way..." "... Section E... Behavior... [MEDICAL CONDITIONS] 0 {indicating no symptom presence} for verbal behavior symptoms directed toward others..." Record review of a document entitled "Minimum Data Set (MDS)" dated 12/29/11 regarding Resident #18 revealed the following: "... Type of Assessment... Quarterly assessment..." "... Brief Interview for Mental Status... Summary Score 15... add scores for questions... (00-15) {indicates the highest score is 15 and lowest is 00}..." "... Section D... Mood... D0200... Resident Mood Interview... 1 {indicating symptom presence} for little interest or please in doing things, feeling down, depressed, or hopeless, feeling tired or having little energy, poor appetite or overeating, feeling bad about yourself - or that you are a failure or have let yourself or your family down..." "... Section E ... Behavior... [MEDICAL CONDITION] ...none of the above... {indicating no symptom presence} for verbal behavior symptoms directed toward others..." Record review of a document entitled "Minimum Data Set (MDS)" dated 05/23/12 regarding Resident #18 revealed the following: "... discharge status .. psychiatric hospital ..." "... Section D... Mood... D0200... Resident Mood Interview... (Blank)..." "... Section D... Mood... D0500... Staff Mood Interview... (Blank)..." "... Section E ... Behavior... [MEDICAL CONDITION] hallucinations... [MEDICAL CONDITION] verbal behaviors symptoms directed toward others... behavior of this type occurred daily..." Record review of a document entitled "Care Plan - (Resident #18)" edited 12/15/11 revealed: "... I will receive antipsychotic medication R/T (related to) dx (diagnoses): [MEDICAL CONDITION] I use medication and will result in maintenance of my function al status... staff will monitor my behavior and response to medication..." Record review of a document entitled "Care Plan - (Resident #18)" edited 12/15/11 revealed: "... I will receive antidepressant medication R/T (related to) depression... Resident's use of medication will result in maintenance in the resident ' s functional status as evidence no depression.... Monitor resident's functional status every day and an as needed... " Record review of a document entitled "Care Plan - (Resident #18)" dated 05/17/12 revealed: "... I have behaviors that interfere with others... I will interact appropriately with staff and resident. X (times) 90 dys (sic)... given prn (as needed) medication when behaviors start... remove from stimuli and return when behaviors stop... document behaviors and notify M.D. ..." Record review of Resident #18's "Care Plans" revealed no identification or interventions for behaviors of other residents affecting the psychosocial well-being of Resident #18. Record review of Resident #23's "Resident Admission Record", dated 10/31/12, revealed a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. In an interview on 12/06/12 at 4:23 p.m. with the Social Worker and Administrator, it was revealed that when Resident #23 was admitted there was a complaint regarding her behaviors by another resident that resulted in the other resident changing rooms. It was revealed that Resident #23 and Resident #18 had verbal altercations. The Social Worker stated that she was aware that Resident #18 had stated that she felt that she would have a psychotic breakdown due to verbal altercations with Resident #23 if something was not done. She stated that she was aware Resident #18 was having trouble sleeping due to Resident #23's outbursts. She stated that she had spoken to Resident #18's daughter, and that the daughter stated that a symptom of beginning [MEDICAL CONDITION] for her mother was trouble sleeping. The social worker stated she did not personally hear Resident #18 make homicidal statements directed at others. The administrator stated that Resident #23 was residing in a private room because they knew they could not place another resident in the room with her. A copy of any investigation or reports conducted for homicidal threats against residents was requested at this time, none were provided prior to exit of this survey. In an interview on 12/06/12 at 5:52 p.m. with Physician A, he stated he told facility that Resident #18 and Resident #23 were both patients of his and that Resident #18 and #23 had a history together. He stated that he previously followed their care at their previous nursing facility. He stated that at times they could be best of friends but at other times they did not get along at all. He stated that in his personal opinion, given the option between keeping Resident #18 and Resident #23, he would have kept Resident #18 at the facility. He clarified this as meaning that due to behaviors Resident #18 were less disruptive then those of Resident #23. In a confidential interview on 12/07/12 at 8:48 a.m. it was revealed that Resident #18 and Resident #23 did not get along. The interviewee stated that the facility did not intervene when the behaviors of Resident #23 affected Resident #18. It was revealed that Resident #23 continues to display behaviors that affect others. The interviewee stated that the facility did not provide interventions to assist Resident #18 when she and Resident #23 began to have problems. Record review of "Social Service Review" signed and dated 1/12/12 by the Social Worker regarding Resident #18 revealed the following: "... Dx (diagnoses): [MEDICAL CONDITION]/paranoid; impulse control disorder; [MEDICAL CONDITION]; Concerns include periods of cycling, which is managed by Nursing, Medical and RX (medication) check; likewise counseling is in place and part of TEAM .... Gets along with roommate and staff and family. Periodically has an outburst or crying spell. At that time she is reassessed per skilled nursing and emotion venues... 1-4-12 had an anger outburst following (sic) by crying.. Skilled nursing and (name of psych services) advised and will assess reason (meds or emotional issue)." Record review of "Notification of Room Change" revealed Resident #18 to have a room change to room [ROOM NUMBER] East due to "bed doesn't move" on 02/29/12. This document was not signed nor dated by resident/resident representative or staff representative. No other "Notification of Room Change" were revealed. Record review of "Psychotherapy Progress Note" dated 04/02/12 regarding Resident #18 revealed: "... (Resident #18) had a tired affect... She talked about two residents with behaviors she found irritating ..." Record review of "Social Service Review" signed 04/05/12 by the Social Worker and dated 4/12/12 regarding Resident #18 revealed the following: "Dx (diagnoses) of [MEDICAL CONDITION]; [MEDICAL CONDITION]. Mental health cycles however is provided services via (name of psych services)l RX (medication) management... She is able to get along well with current roommate, staff, and other residents. Has become good friends with another resident...". Record review of "Psychotherapy Progress Note" dated 04/11/12 regarding Resident #18 revealed: "... (Resident #18) had a happy affect... she was easy to engage, very verbal. Her affect remained cheerful..." Record review of "Psychotherapy Progress Note" dated 04/18/12 regarding Resident #18 revealed: "... (Resident #18) smiled and was open, alert, easily engaged and verbally responsive..." Record review of " Psychotherapy Progress Note " dated 04/25/12 regarding Resident #18 revealed: "... (Resident #18) smiled and was open, alert, easily engaged and verbally responsive ..." Record review of Physician A's "Progress Note" dated 04/25/12 regarding Resident #18 revealed: "The patient indicates she wants to go eat today. She indicates everything is generally pretty good. Meeting with nursing staff indicates the patient's sleep , appetite and energy levels are good. OBJECTIVE: The patient is interactive. She appears euthymic (normal non depressed, reasonably positive mood) with a relative affect. Speech and thought are without gross abnormality. No suicidality." Record review of " Psychotherapy Progress Note " dated 04/30/12 regarding Resident #18 revealed: "... (Resident #18) was lethargic, not open, nor easily engaged or very verbally responsive... She made negative comments about staff and said she needed help for her hernia... " Record review of "Psychotherapy Progress Note" dated 05/02/12 revealed: "... (Resident #18) was lethargic, not open, nor easily engaged or very verbally responsive ... She made negative comments about her physician and said he hasn't come to see her for some time ... Mood did not improve during session... " Record review of " Psychotherapy Progress Note " dated05/09/12 regarding Resident #18 revealed: "... (Resident #18) was lethargic, not open, not easily engaged nor very verbally responsive... Mood did not improve during session..." Record review of "Psychotherapy Progress Note" dated 05/14/12 regarding Resident #18 revealed: "... (Resident #18) was lethargic, nor open, not easily engaged nor very verbally responsive. (Resident #18) cried and said she was tired of being sick and in pain... Mood did not improve during session..." Record review of a facility document entitled "Re: (Resident #18)" revealed the following: "... 05/14/2012 ...(Legal Guardian of Resident #18) advised MSW that she feels her Mother is ' about to have a relapse', i.e. with DX (diagnoses) of [MEDICAL CONDITION]. She said she has dealt with her ups and downs and know that one of the first signs is 'sleep deprivation'..." "... 05/15/2012... (Resident #10) was moved to room West 3B from East 25B..." "... 05/16/2012... Began crying loudly while in hallway in front of public bathroom; said to MSW 'I don't know why these people are being so mean to'; MSW asked who ... she said "(Resident #23), she's being loud and cursing at me and following me around'. She also said 'this is my Kingdom and I'm God, why do they do that?"... "Also I spoke to (Resident Name) and said said (sic) 'Shut up, don't talk to me'. 'Why do they have to be so mean'?... Began crying in the lobby ... (Resident #18) said '(Resident #23) is still following me around, raising hell, cursing at me last night... 'she said my people gonna come down here and kill you'... MSW then asked why she thinks should be done (sic). She said 'She needs to be killed.' MSW asked why are you gonna do (sic)? She said 'I gotta kill her cause this my Kingdom.' MSW 'how?' (Resident #18) said 'I'm gonna shoot her bed off; while she's in it.'..." Record review of Physician D's "Progress Note" dated 05/16/12 regarding Resident #18 revealed: "This patient has been having [MEDICAL CONDITION] with [MEDICAL CONDITION] lately... She is being managed with regard to her mental status by (Physician A) This patient has had previous hospitalization s for serious mental breakdown when she gets severe psychotic episodes [MEDICAL CONDITION] depression. (Physician A) has adjusted her medication and hopefully this will avert any psychotic problems at this point..." Record review of "Daily Skilled Nurse's Note" dated 05/15/12 regarding Resident #18 revealed "... Notified (Physician A) of res behavior (talking about homicide, etc) N.O. (new order) received for [MEDICATION NAME] (a prescription medication used to treat [MEDICAL CONDITIONS] disorder, and depression) 10 mg po (by mouth) qhs (every night)...". Record review of "Daily Skilled Nurse's Note" dated 05/16/12 regarding Resident #18 revealed "...Res. Up in lobby crying, stating I finally slept last night, first time in 4 days, felt so good. Told the aides God gave her a baby, that why she is so heavy... Daughter stated "She acts like this, when she s about to have a psychotic break ...". Record review of "Psychotherapy Progress Note" dated 05/16/12 regarding Resident #18 revealed: "... (Resident #18) was agitated, teary, very verbally responsive. (Resident #18) said she was no longer in pain but had been moved to another hall because of a noisy resident living nearby ... Mood did not improve during session..." Record review of "Daily Skilled Nurse's Note" dated 05/17/12 regarding Resident #18 revealed "...Res. Was cusing this am, when she got up for breakfast. Went to D/R (dining room). Was laughing and talking with staff... (Physician A) was called, new order to call him daily with her behaviors and he will adjust her meds, he wants to keep her here as long as he can... physical aggression res. -illegible- stating I ' m going to tell another res. to stop talking to me about me.... Res. crying in her room (9). Telling another res to stop talking about me and cusing me...siting in lobby earlier this evening stated she was going to kill a certain res. on the other unit...". Record review of "Daily Skilled Nurse's Note" dated 05/22/12 regarding Resident #18 revealed "...Res. stating I ' m going to kill everyone they -illegible- me. Talking with (ADON A). Wanted me to call (Physician A) to see if we could move her out of the unit, to a private room. The other res. are upset...". Record review of "Nurse's Note" dated 05/23/12 regarding Resident #18 revealed "... Resident very restless, agitated, crying and screaming, cursing, going in and out of other residents rooms. Refused to follow commands or redirection ...". Record review of "Daily Skilled Nurse's Note" dated 05/23/12 regarding Resident #18 revealed "... Resident restless, cursing, and yelling... sent resident to inpatient hospital for psychological services ...". Record review of Physician A's "Progress Note" dated 05/24/12 regarding Resident #18 revealed: "I received several phone calls on the patient. She had been transferred to (Name of Hospital) psychiatric hospital." Record review of Physician A's "Progress Note dated 06/21/12/12 regarding Resident #18 revealed: "The patient is in the psychiatric hospital." No other notes from Physician A were provided regarding interventions or care provided to Resident #18. 2. Observation on 12/05/12 at 10:30 a.m. revealed Resident #23 to be hollering and throwing hangers in her room loud enough to be heard in the hallway. A CNA was observed to enter Resident #23 ' s room and ask if she was ok. Resident #23 asked what she meant, and the CNA stated " well I heard something fall and I wanted to make sure you were ok " . Resident #23 yelled at the CNA " You stupid [***] ! Don ' t you know the difference between a body hitting the floor and a hanger? " . In an interview on 12/05/12 at 12:00 p.m. Resident #25 stated she complained that the resident across the hall, clarified as Resident #23, is loud and obnoxious. Observation on 12/06/12 at 8:00a.m., revealed Resident #23 crying and speaking loudly in the doorway of her room. Resident #23 said that she was upset because "they said that she had to pay the money back and that she didn ' t have any money." In an interview on 12/06/12 at 4:12 p.m. with Resident #24 it was revealed that previously she had requested a room change due to outburst by Resident #23. She stated that it made it difficult for her to sleep. She stated that now she resides in a room near Resident #23 again, and that she knows that if Resident #23 ever tried anything she would have to stop her herself. She stated that she was fearful of Resident #23's behaviors but that it did no good to complain because they, clarified as staff, won't do anything. In an interview on 12/06/12 at 1:25 p.m., the Administrator said both Resident #18 and Resident #23 were in rooms on the east side of the building. The Administrator said Resident #18 had requested a room change. The Administrator said she did not know of any problems after Resident #18 changed rooms. The Administrator said Resident #18 was a social person, and that Resident #23 stayed to herself. Record review of a document entitled "Minimum Data Set (MDS)", dated 03/23/12, regarding Resident #23 revealed the following: "... Type of Assessment... Admission assessment..." "... Brief Interview for Mental Status... Summary Score 6... add scores for questions... (00-15) {indicates the highest score is 15 and lowest is 00}..." "... Section D... Mood... D0200... Resident Mood Interview... 1 {indicating symptom presence} for little interest or please in doing things, feeling down, depress, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy... trouble concentrating on things, such as reading the newspaper or watching television..." "... Section E... Behavior... [MEDICAL CONDITIONS] 0 {indicating no symptom presence} for verbal behavior symptoms directed toward others and other behavioral symptom's not directed toward others... 3 {indicating behavior of this type occurred daily}..." Record review of a document entitled "Minimum Data Set (MDS)", dated 06/22/11, regarding Resident #23 revealed the following: "... Type of Assessment ... Quarterly assessment..." "... Brief Interview for Mental Status... Summary Score 12... add scores for questions... (00-15) {indicates the highest score is 15 and lowest is 00}..." "... Section D... Mood ... D0200. Resident Mood Interview... 1 {indicating symptom presence}... little interest or please in doing things, feeling down, depress, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy..." "... Section ... Behavior... [MEDICAL CONDITIONS] 0 {indicating no symptom presence} for verbal behavior symptoms directed toward others and other behavioral symptom's not directed toward others... 3 {indicating behavior of this type occurred daily}..." Record review of Resident #23's " Care Plans" revealed the following: "... 04/18/12... I receive antianxiety medication R/T (related to) anxiety..." "... 04/16/12... I receives (sic) antidepressant medication R/T (related to) depression secondary to my [MEDICAL CONDITION] diagnosis..." "... 04/16/12... I have [MEDICAL CONDITION] R/T (related to) my [DIAGNOSES REDACTED].. " "... 04/25/12 ... I have behaviors that interfere with the care/privacy of others. I also demonstrate violent behaviors at times... I will interact peacefully and appropriately with other residents and staff x (times) 90 days...staff will keep distance beween resident and others during delusional periods ... staff will not confront, argue against, or deny resident's belief system ... staff will provide safe, quiet, low-stimuli environment during delusional periods..." This care plan was signed on 05/17/12, 06/7/12, and 10/4/12. No new interventions or approaches were added after 04/25/12 when goals were not met for the time period before. Record review of a document entitled "Diagnostic Interview Examination Form" signed and dated 04/25/12 regarding Resident #23 revealed ".... (Resident #23) presents with anger, anxiety, agitation, mood swings, tearfulness, disruptive behaviors, and adjustment difficulties... She is having difficulty adjusting to transition to a different NH (nursing home)....". Record review of Resident #23's "Psychotherapy Progress Note" signed and dated 04/30/12 revealed "... (Resident #23) was agitated, not easily engaged nor cooperative. She was verbally responsive. (Resident #23) appeared to be manic today. Her thoughts were not focused and she appeared to jump from one people to another. (Resident #23) made negative comments about the NH (nursing Home)... Mood did not improve during this session ...". Record review of a document entitled "Re: (Resident #23)" signed by the Social Worker revealed the following: "... Resident has experienced several episodes of outbursts which include cursing, yelling and screaming, according to other residents. On 3/18/2012, as per nursing notes, Resident was in her room crying, screaming and yelling. Nursing staff redirected her however; she was uncooperative and refused to follow command..." "... 3/23/2012... According to 6 am - 6 pm nursing notes, Resident was yelling and cursing at staff; rolling up and down the halls. Asked per East Charge nurse, (Staff Name), to not yell in the hallway; asked what is wrong; Resident said 'can't I talk to myself'? (Staff) agreed she could but no to yell due to other Residents disruption..." "... 04/02/2012... Complaint via Resident's roommate's family, advising that when they visit, Resident is always asking for something to eat. Complainant stated it is an annoyances for the family to visit and contend with the Resident..." "... 04/06/12... Resident moved to room E24D (with {Resident Name})..." "... 04/06/12... Slight argument noted in nursing notes between (Resident #23) and (Resident Name) about territory of the room. (Should be noted this a 4/ quad Resident room)..." "... 04/07/12... According to nursing notes, Resident in her room yelling and pushing night stand into cabinet; yelling about 'why was I moved?'... She continued to talk non-stop about her being moved..." "...04/08/12... Complaint via (Resident name), Resident's roommate, saying Resident keeps her up at night yelling, hollering and screaming..." "... 04/08/12... Resident yelling at roommate, telling her to shut her mouth and get out of her room..." "... 04/21/12.... Resident in dining room, yelling and cursing at everyone; several family members left the dining room because of the yelling and cursing and throwing things. Resident was taken to her room. Resident then took all the covers/sheets off of her bed and threw them onto the floor; threw items out of her drawers onto the floor; attempted to calm Resident however door had to be closed..." "... 04/24/12... Resident resting in W/C (wheelchair) in her room; yelling, screaming (and) throwing things around. When East Wing LVN (Staff Name), attempted to redirect her, Resident said 'You are not my boyfriend and you cannot tell me anything'. Was not able to redirect Resident due to excessive yelling..." "...04/30/12... Resident throwing spoons and yelling at staff to 'get out of my room and leave me alone'..." "... 05/06/12... Resident yelling and cursing at staff; threatening to hit staff. Was given PRN (as needed) medication, however, was not effective..." "... 05/08/12... 6:45 am - according to nursing charge, (Staff Name), Resident was yelling, cursing, screaming and disturbing other Residents. (Staff) attempted to quiet Resident, however, she would not when asked to lower her voice, getting aggressive... Resident continues to yell, curse and scream..." "... 05/12/12... 5:00 am - Resident sitting up in W/C (wheelchair) all night; refused to lay in bed... Was screaming, yelling and cursing at other Residents; combative with staff..." "... 05/14/12... Resident yelling, throwing things, slamming door on closet until it came off the hinges. Resident then kicked door then yelled my foot, my foot; when asked which foot hurt, Resident stated both of them hurt, not that anyone cares; non (sic) of you care about me. LVN (licensed vocational nurse) asked Resident to calm down and talk to the LVN. However she continued throwing clothes, yelling 'get out , get out'... While Resident was in the shower, became very agitated w/CAN (sic/Certified Nursing Aide), yelling and screaming saying 'you the reason for all the lumps on me; it is all your fault... Resident continuing to yell and scream at staff..." "... 05/15/12... Resident refused to have Accu check done; swinging arms yelling, 'hell no, leave me alone'... Resident in room yelling at staff 'you don't do nothing for me'. Resident has pulled cover off of bed and thrown it on the floor..." "... 05/16/12... MSW (Medical Social Worker) was contacted by a Resident (unmaned resident) who resides across the hall from Resident (#23), stating she is being kept awake at night due to Resident's continued screaming and yelling and cursing. She said it was making her ill and causing stress...." Record review of Resident #23's "Psychotherapy Progress Note" signed and dated 05/07/12 revealed "(Resident #23) was agitated, not easily engaged nor very cooperative. She was verbally aggressive and appeared to be confused. (Resident #23) appeared to be manic today. Her thoughts were not focused and she appeared to jump from one problem to another... Mood did not improve during the session...". Record review of Resident #23's "Progress Note" signed and dated by Physician A 05/24/2012 revealed "... Meeting with nursing staff indicates the patient has been loud and aggressive. I have received several phone calls...". Record review of Resident #23's "Care Plan Conference Summary " , dated 07/05/12 revealed: "... yelling crying... No changes recommended with plan of care..." and to be signed by LVN F, the Dietary Manager, the Activity Director, and the Social Worker. Record review of Resident #23's "Progress Note" signed and dated by Physician A 07/25/12 revealed "... The patient indicates she "Hadn't done nothing" even though people might have told me that she didn't do anything. She just woke up. Meetings with nursing staff indicates the patient still yells out at times but is not as severe...". Record review of Resident #23's "Care Plan Conference Summary" dated 10/04/12 revealed "... yells, can be demanding... Reviewed current plan of care with IDT (Inter Disciplinary Team). No changes are recommended..." and to be signed by LVN F, LVN G, the Dietary Manager, the Activity Director, the Social Worker and the Director of Nurses. No additional information regarding incidents/investigations were provided prior to exit. The facility provided CMS 672, signed and dated 12/03/12 by ADON B revealed 25 residents identified with behavior symptoms.

Based on interviews and record reviews the facility failed to implement policies and procedures that prohibit neglect of residents. The facility failed to ensure 2 of 4 reviewed residents (#1 and #2) were provided the services necessary to avoid physical harm, mental anguish and death as evidenced by: a) failure to thoroughly assess and consult with Resident #1's physian (or physician on-call), or send the resident to the ER for evaluation after the resident fell and sustained a head injury on [DATE]. The resident died on [DATE]. b) failure to assess Resident #2, consult with her physician, and honor her requests on [DATE] when she developed nausea, vomiting, diarrhea, complained of abdominal pain, and was requesting to go to the hospital. Resident #2 suffered a cardiac/respiratory arrest at the facility and was pronounced dead in the ER later that same morning. These failures resulted in an Immediate Jeopardy (IJ). The IJ was called on [DATE]. The immediacy was removed prior to exit on [DATE]. The noncompliance continued at a level of pattern with actual harm that is not immediate jeopardy. Any of the 80 residents in the facility could be affected by these deficient practices. Failure to assess residents' and consult with a physician regarding an injury or a change of condition could result in negative resident outcomes, including death, due to not receiving appropriate medical interventions. Finding included: 1. Record review of Resident #1's Admission Record revealed Resident #1 was an [AGE] year old female, original admitted [DATE] with [DIAGNOSES REDACTED]. Record review of an incident report initiated and signed by LVN E dated [DATE] at 8:15 a.m. revealed that Resident #1 was in the bathroom; she lost her balance and fell , hitting the left side of her head on floor causing a five cm hematoma as well as two skin tears to her left hand. Skin tears measure 1.7 cm X 0.2 cm and 1.1 cm X 0.3cm. Resident #1 had full range of motion to all extremities; no other bruises or redness noted. Resident #1 complained of pain in head and neurological checks were initiated. LVN E wrote on the incident/accident report that she had notified Resident #1's PCP at 9:30 a.m. on [DATE]. Record review of incident investigation (undated) by Administrator and ADON 1 revealed the following: The investigation shows that on [DATE] Housekeeper 1 witnessed the fall on the morning of [DATE]. CNA E was making a bed. Housekeeper 1 was in the room, heard a 'thud', saw Resident #1 falling from the adjoining bathroom into room [ROOM NUMBER], hit her head on the dresser and continued to fall to the floor. Both CNA E and Housekeeper 1 tried to get to Resident #1, but were unable to because Resident #1's walker was in the bathroom in front of the sink. CNA E moved it (the walker) out of the way to try to assist her, and then went to the door to call for help as Housekeeper 1 left the room to get help. All staff reported Resident #1 was trying to get up from the floor while they were assessing and monitoring her. Further review of the facility investigation revealed CNA F, LVN E, and CMA 1, entered the room. ADON 2, entered and noticed a skin tear on the resident's hand. Resident #1's right leg was "out of alignment" and ADON 2 evaluated and determined Resident #1 was able to move extremities within her normal abilities. A hematoma was noted on the left side toward the back of her head. Vital signs were taken while Resident #1 was still on the floor. There was no evidence of documentation of the vital signs taken, while the resident was on the floor, in Resident #1's clinical record. Further review of the facility investigation revealed Resident #1 was assisted up from the floor with a gait belt by CMA 1, LVN E and CNA F. Resident #1 ambulated to her room with assistance of staff and sat in her recliner. LVN E initiated neurological checks. Resident #1 was trying to get up from the recliner without assistance. Between (sic) LVN E and CMA 1 they remained in her room. LVN E continued neurological checks. Resident #1 was reportedly up most of night (Friday night) and slept most of day on Saturday. Sunday Resident #1 was back to ambulating between the lobby and her room. Review of Resident#1's clinical record revealed no evidence of documentation that the resident's PCP was notified of her change of condition. In an interview with ADON 2, on [DATE] at 3:25 p.m. he stated that on [DATE] between 8:00 a.m. and 8:30 a.m. he heard CNA E holler that someone was on the floor. He saw that the Resident #1 was on the floor with the top half of her body in room [ROOM NUMBER] and the lower half of her body in the adjoining restroom; the resident was trying to get up off of the floor. ADON 2 left to answer another resident's call light, came back to assist with Resident #1, and the other people in the room (CMA 1, LVN E, CNA F) were obtaining vital signs. ADON 2 said Resident #1 had a bump on back of her head; he heard the nurse say "hematoma". ADON 2 demonstrated to surveyors that the bump was about middle of the back of her head, "a small bump", about nickel sized, egg shaped, with no blood noted. ADON 2 noted skin tears to Resident #1's left hand, and was concerned that her right leg was "going outward". He was concerned about a possible [MEDICAL CONDITION]. After ascertaining Resident #1 was able to move the right leg, ADON 2 stated that he went back to his office. He said he did not get report on her vital signs and did not notify the resident's PCP. He said he did not feel that Resident #1 needed to be sent to the emergency room to be evaluated at that time. Review of the resident's clinical record revealed no evidence of documentation that ADON 2 notified Resident #1's PCP. In an interview with LVN E on [DATE] at 3:55 p.m. concerning Resident #1 falling on [DATE]; LVN E stated that she heard "a loud noise" and went into room [ROOM NUMBER] to find Resident #1 sitting on the floor in the doorway to the bathroom. She said she did a full head to toe assessment, that Resident #1 had full range of motion, noted a "knot" on the left side of her head and two skin tears to the left hand. LVN E stated that she gathered up all of her charting and took it to Resident #1's room to stay with her in order to "keep an eye on her", initiated neurological checks and an incident/accident report. LVN E stated that she spent most of the day in Resident #1's room. She and CNA E were talking about having pizza for lunch, Resident #1 overheard and wanted pizza also, and so LVN E and CNA E shared their pizza with Resident #1. LVN E stated that Resident #1 complained of a headache, so she gave her some Tylenol. LVN E stated that she received a call from the resident's PCP office nurse concerning another resident and LVN E told the office nurse about Resident #1's fall. LVN E was not clear in this interview about what details she reported to the office nurse concerning Resident #1's fall or her condition following the fall. LVN E went on to state that she did notice that Resident #1's blood pressure was low in the beginning, but she does not remember if she reported it or not. LVN E stated she did not feel that Resident #1 needed to go to the emergency room to be evaluated at that time. Record review of physician order sheets dated [DATE] initiated by LVN C, revealed an order to clean Resident #1's skin tears with normal saline, apply TAO, and cover with a light dressing daily and as needed until healed. There was no evidence of any documentation of physician orders related to the 5 cm hematoma to the left side of Resident #1's head. Review of the neurological assessment sheet revealed blood pressure and pulse rates taken and recorded after the resident was moved from the floor to her recliner: [DATE]: 8:15 a.m. BP ,[DATE] (low), P 116 (high) 8:30 a.m. BP ,[DATE] (low), P 70; 8:45 a.m. BP ,[DATE], P 86; 10:00 a.m. ,[DATE] (high), P 68; 10:30 a.m. BP ,[DATE] (high), P 68; 12:00 noon BP ,[DATE] (high), P 76. [DATE]: 3:00 p.m. BP ,[DATE], P 74; [DATE]: (no time) BP ,[DATE], P 84. There was no evidence of documentation that any of these readings were communicated to Resident #1's PCP. Record review of Nurses' Notes dated [DATE] at 8:15 a.m. by LVN E revealed: "heard loud noise and found this resident on floor in doorway of bathroom, lost balance and fell - hit left side of head on floor causing five cm hematoma and two skin tears on left hand (1.7 cm X 0.2cm) and (1.1 cm X 0.3 cm), area cleansed with normal saline, triple antibiotic ointment and light dressing applied - Neurological checks initiated - full range of motion to all extremities; no other bruises or redness noted at this time, (ADON 1), PCP and family notified - sitting in recliner and up to bathroom several times with walker and assistance." There was no evidence of notation about the initial low BP and elevated pulse rate being communicated to the PCP. Record review of Nurse's Notes dated [DATE] at 6:00 p.m. by LVN D revealed: "sitting in recliner. Resting; Complained of headache, took as needed dose of Tylenol 500 milligrams po given." In an interview with CNA D on [DATE] at 10:35 a.m. he said for a couple of days before the second fall (on [DATE]) Resident #1 had been more confused than usual. He said she kept repeatedly asking for help to go to the bathroom. In an interview with CNA H on [DATE] at 2:53 p.m. she said she worked the two days after Resident #1's first fall ([DATE]). She said the resident was not eating (feeding herself) and had to be fed by staff at least one meal on Saturday ([DATE]). She said she noticed when the resident was in her recliner she was leaning 45 to 90 degrees to the left. In an interview with CNA G on [DATE] at 3:55 p.m. she said she has worked at this facility since ,[DATE] and has been a CNA since 1995. CNA G stated she was not working during either of Resident #2's falls, but did work Saturday [DATE], the day after the first fall, and Sunday [DATE]. CNA G went on to state that on that Saturday, Resident #1 stayed in her room, and slept most of day, which was very unusual for Resident #1, and Resident #1 stated "I don't feel good." CNA G stated that on Sunday [DATE] during the day Resident #1 was up and about in her usual manner, but was more confused than usual. Record review of a second Incident/Accident Investigation Worksheet dated [DATE] at 7:00 p.m. by LVN D revealed: "Resident fell in front lobby; witness by two aides..."paged MD on call - no response" (no time). Resident #1 was sent to a local hospital emergency room (ER) at 7:35 p.m. Record review of Nurses Notes dated [DATE] revealed that Resident #1's second fall occurred on [DATE] in the evening around 7 p.m. Resident #1 continued the same routine, ambulating to the lobby and back to the bathroom. Resident #1 was sitting in the green chair in the lobby, attempting to get up, and requested help. CNA C assisted her up and the resident ambulated toward the back of the couch, went to turn back toward the green chair after she complained of shortness of breath. CNA C was at Resident's # 1's side and called for CNA D's assistance as CNA C was attempting to get the resident seated. Resident #1 yelled, "I'm falling", then let go of her walker and fell backwards hitting her upper back on the shoulder of the couch. LVN D assessed Resident #1, noted an old purple bruise to left side of head (from the fall on Friday [DATE]). No other new bruises, hematomas or new skin tears were noted. Resident #1 complained of a headache and hurting all over. Record review of the ER notes from local hospital dated [DATE] revealed that Resident #1 was agitated, repeatedly requested "help me, somebody please help me." Resident #1 complained of headache, blood pressure and heart rate elevated (initial BP ,[DATE], P 111 at 7:48 p.m.); at 8:20 p.m. Resident #1's BP was ,[DATE], no pulse rate recorded); pupils were sluggish and the resident needed to be restrained due to continued agitation. Record review of the Radiology and Nuclear Medicine reports from local hospital dated [DATE] at 7:59 p.m. revealed, "An acute 1.3 cm right sided subdural hematoma is seen with midline shift from right to left approximately 0.7 cm. Left parietal scalp swelling/hematoma is present. No underlying fractures identified. Mild cortical and cerebellar atrophy is present. Impression: "1. Acute right sided subdural hematoma with midline shift; 2. Left parietal soft tissue swelling." According to <http://www.medlineplus.com>: "An acute subdural hematoma (SDH) is a rapidly clotting blood collection below the inner layer of the dura but external to the brain and arachnoids' membrane. A subdural hematoma (SDH) is the most common type of intracranial mass lesion, occurring in about a third of those with severe head injuries. Subdural hematoma is more common in people older than [AGE] years. The elderly are predisposed to cerebral atrophy because they have less resilient bridging veins. Moreover, these veins can be damaged more easily in the elderly. Suspect acute subdural hematoma whenever the patient has experienced a mechanism of moderately severe to severe [MEDICATION NAME] head trauma." Record review of Physician's Progress notes from local hospital dated [DATE] at 9:50 p.m. by neurological admitting physician revealed, "Diagnosis: [REDACTED]." Record review from the Department of Radiology and Nuclear Medicine from local hospital dated [DATE] at 8:00 a.m. revealed: "Impression: Significant enlargement of the patient's (Resident #1) right subdural hematoma..." Record review of the Progress Notes from local hospital dated [DATE] revealed: "Death Note...Time of death was at 1343 (1:43 p.m.)." In a telephone interview with Resident #1's physician office nurse on [DATE] at 10:42 a.m., she stated that the PCP was out of town from [DATE] to [DATE]. She said she checked all of the telephone logs for the PCP and the covering physician from that time period, particularly [DATE] when LVN E stated that she had notified the PCP's office. There was no evidence of any calls to or from the facility on [DATE]. In an interview with the facility's Medical Director on [DATE] at 1:00 p.m., he stated he was not notified of Resident #1's change of condition. He stated that the protocol was to send any resident to the emergency room at any time the resident requests, or at any time there is a change of condition. The Medical Director stated that the staff must notify the DON first, then the attending physician or the covering physician and if either physician were not available to call him (the facility Medical Director). During an interview with ADON 1 on [DATE] at 1:50 p.m. she said she was off on [DATE] when Resident #1 fell . She said the facility did not have a DON at that time and she (ADON 1) was not notified of the incident. She said, in hindsight, Resident #1 should have been sent to the ER for evaluation after falling and hitting her head. In a telephone interview with the Neurologist for Resident #1 on [DATE] at 5:05 p.m., he stated that when the resident was admitted to the hospital he was not aware that she had fallen and struck her head on [DATE]. He stated that through his record review and the condition of Resident #1's subdural hematoma, that the subdural hematoma likely occurred during the first fall on [DATE], especially since she did not strike her head during the second fall on [DATE]. The neurologist went on to state, "Any time any resident falls, whether it was a witnessed fall or an unwitnessed fall, if there is any suspicion the resident might have hit their head on anything, the resident needs to be evaluated immediately at the ER." 2. Record review of Resident #2's Admission Record revealed she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Her CPR status was Full Code. Record review of the MDS assessment dated [DATE] revealed her speech was clear, she was able to comprehend others, was able to express herself and make herself understood. She required extensive assistance of two people for bed mobility. She was not able to ambulate and was confined to the bed or wheelchair. She required extensive assistance for dressing toileting and bathing. She had an indwelling urinary catheter and a [MEDICAL CONDITION]. She was 4' 8" tall and weighed 68 lbs. Record review of the facility's investigation report by ADON 1 dated [DATE] revealed the following: 1) At approximately 1:30 p.m. CNA A and CNA B came to her office and reported that the charge nurse (LVN A) was aware that Resident #2 wanted to go to the hospital, she had been sick all day, and just wasn't acting right. After being notified of this, ADON 1 documented that she and the Administrator called LVN A into the office to speak with her. The interview revealed that she was aware of Resident #2 vomiting, her complaints of stomach pain, and not feeling well. LVN A was also aware of the resident's requests to go to the hospital, but could not explain why she did not send the resident to the hospital. 2) LVN A documented that a fax was sent (no time noted) to Resident #2's physician concerning her vomiting and requesting some other medication besides [MEDICATION NAME] for this. This physician requests all faxes to be placed in his box at the facility and he addresses them when he comes in to make rounds, which is usually after lunch, and LVN A was aware of this. LVN A did not call the Resident's physician regarding her change of condition. 3) LVN A documented in the nurses' notes that Resident #2 had vomited in the dining room, but investigation revealed the resident did not get out of bed that morning. Breakfast had been brought to her room but she refused everything except cream of wheat. CNA A was monitoring the hall while CNA B was feeding residents' breakfast in the dining room. At approximately 8:15 a.m. LVN A went to the dining room to get CNA B to go assist CNA A to clean up Resident #2 after she had an episode of vomiting. Both CNA A and CNA B reported to LVN A that the resident had complained of not feeling well, complained of stomach pain, did not look well and had slurred speech. 4) LVN B (medication nurse) went to Resident #2's room (no time noted) to give her a pain pill ([MEDICATION NAME]) which she refused at that time because of nausea and vomiting. LVN B gave the resident [MEDICATION NAME]. 5) At approximately 9:00 a.m. CNA A, CNA B, and LVN C (treatment nurse) were in Resident #2's room, changing her [MEDICAL CONDITION] bag after an episode of diarrhea. LVN A came into the room and CNA B was talking to the resident, and the resident was saying she wanted to go to the hospital. LVN C said she did not hear her say that but did say the resident "did not look right". LVN C said she asked the resident what was wrong and the resident said she didn't know but something was not right, but could not explain what. LVN C left the room and thought that LVN A would call the doctor. LVN C said she was not aware Resident #2's physician was not notified until after the resident had coded. 6) LVN A said Resident #2 (no time noted) turned on her call light. When she went to the resident's room she was short of breath, her O2 sats were in the 90's (normal) so she elevated the head of the bed. The oxygen was continuous and was in place. LVN A said the resident acted like she wanted to get out of bed. As LVN A was leaving the room she saw CNA B as she was taking a resident to the dining room for lunch and told her go ahead and get Resident #2 up for lunch, it might help her stomach. 7) CNA B went to Resident #2's room then left to get a washcloth (no time noted). She told LVN A that the Resident did not look good. CNA B returned to the resident's room and found her with her eyes wide open and her left arm shaking. CNA B summoned LVN A. LVN A was unable to get a blood pressure on the resident. ADON 1 was summoned. She found the resident unresponsive, pupils fixed and dilated, with no pulse or blood pressure. CPR was initiated and 911 was called. Fluids kept coming from the resident's mouth requiring her to be suctioned intermittently. The fire department arrived and took over CPR. The ambulance arrived and the resident was taken to the ER. Record review of the Provider Investigation Report dated [DATE] revealed Resident #2 had a history of [REDACTED]. The incident occurred on [DATE]. Under Description of the Allegation it was documented that the resident had nausea and vomiting and requested to go to the hospital. Resident was given [MEDICATION NAME] (a medication for indigestion) and [MEDICATION NAME] (a pain medication). Resident was found unresponsive at 10:50 a.m. Under Description of Injury it was documented that the resident was found unresponsive with no pulse or blood pressure. Her pupils were fixed and dilated. Under Description of Assessment it was documented that vital signs were assessed and CPR initiated. Under Provider Response it was documented that the initial assessment was incomplete because resident request was not honored and physician not notified of change in condition. Record review of the nurses' notes revealed the following entry on [DATE] by LVN A: (No time entered) "Resident up in w/c to D/R for breakfast. Started c/o stomach hurting. [MEDICATION NAME] 30cc P.O. given for discomfort. Vomited small amt. emesis - Resident put back to bed. Positioned on left side - [MEDICAL CONDITION] bag changed, had loose stool." "0930 (9:30 a.m.) C/o stomach still hurting. [MEDICATION NAME] 1 p.o. given (50 mg)." (No time entered) "ADLs done by staff - Foley catheter patent ..." (No time entered) "Fax to Dr.___ about vomiting ask for something else besides [MEDICATION NAME]." Review of a fax to Dr. ___ dated [DATE] (no time) revealed the following: " *comments: (Resident #2) Resident vomited x1 at breakfast table - brought back to room [MEDICATION NAME] was given still complained of pain [MEDICATION NAME] 50 mg 1 p.o. given - Resident had loose stool - [MEDICAL CONDITION] bag was changed. Resident confused at times - Could we have something else for nausea besides [MEDICATION NAME]" Further review of nurses' notes dated [DATE] by LVN A revealed the following: "1050 (10:50 a.m.) Resident sleeping appears to be resting comfortably...resident turned on call light when nurse went to room resident was talking - stated she was SOB. - O2 sat. 98% HOB (elevated) when nurse asked if she wanted to sit up in w/c she acted as if she was going to get out of bed - Ask CNA to help her get up - when CNA entered room resident was not responding - pupils were dilated - Crash cart was brought to room and 911 called. CPR initiated by (ADON 1) and (ADON 2) - Resident vomited large amount brown liquid. Resident suctioned obtained small amt brown liquid - 02 via nasal cannula at 3 LPM - Resident still unresponsive. " "1115 (11:15 a.m.) ___ Ambulance here CPR administered by ___ Ambulance - unable to obtain heart beat. Resident transferred to (hospital)." Review of the hospital emergency room records revealed Resident #2 arrived in theER on [DATE] at 11:35 a.m. with CPR still in progress. The ER physician and staff were unable to revive Resident #2 and she died . Her death was pronounced at 11:46 a.m. During an interview with LVN B on [DATE] at 11:25 a.m. she said she was told on [DATE], around breakfast time, by LVN A that Resident #2 needed something for pain. She said she took the resident an [MEDICATION NAME] but the resident said she couldn't take it because she was nauseated. LVN B said she gave her [MEDICATION NAME] instead at that time and returned later and gave her the [MEDICATION NAME]. LVN B said she started working at the facility a couple of months ago on a prn basis. She said they call her to work if someone calls in. She said she thought [DATE] was only her second time to work in the facility and said she "really didn't know these residents." LVN B did not assess the resident and did not notify the resident ' s physician of her change of condition. During an interview with CNA A on [DATE] at 11:35 a.m. she said Resident #2 didn't want to get up for breakfast that morning ([DATE]). She said she took her breakfast tray to her room but she didn't want anything. She said she was passing the other hall trays when the med nurse (LVN B) told her that Resident #2 had vomited. She said she got CNA B to help her clean up the resident. She said Resident #2 was asking to see the doctor or to go to the hospital. She said as the morning went on she "just wasn't herself." She complained of aching and having mid-abdominal pain. She said "she was not as talkative as usual and was more withdrawn, and she just kept saying she hurt and needed to see the doctor." She said LVN A was aware that Resident #2 was asking to go to the hospital. During an interview on [DATE] at 2:10 p.m. ADON 1 said she was in charge at the facility on [DATE]. She said she was unaware of Resident #2's change of condition or her requests to be sent to the hospital that morning. She said when she responded to the code, Resident #2 was not breathing and had no blood pressure or pulse. She said she initiated CPR and had 911 called. She said they had to interrupt CPR several times to suction dark brown fluid from the resident's mouth. ADON 1 said that her investigation revealed that no one (LVN A, B or C) had notified Resident #2's physician of her change of condition or her requests to be sent to the hospital. She said LVN A had just put a fax in the doctor's box asking for something besides [MEDICATION NAME] for her nausea and vomiting. During an interview with LVN A on [DATE] at 4:30 p.m. she said that on [DATE] around 8:30 a.m. she was told by CNA B that Resident #2 had vomited. She said she asked LVN B (medication nurse) if she had given the resident anything for nausea and that LVN B said she had given her [MEDICATION NAME]. LVN A said she went to the resident's room to check on her and the resident said her stomach was hurting. She had diarrhea in her [MEDICAL CONDITION] bag. LVN A said the resident settled down for a little while but was woke up by hammering in a nearby room that was being renovated. She put on her call light and said she was not feeling good. LVN A said she had faxed the doctor and he would see her when he made rounds. She said Resident #2 did ask to go the hospital but she had only vomited once. She said Resident #2 had so many things wrong with her it was sometimes hard to know what was going on with her. When asked if she assessed the resident that morning she said, "I looked at her, but I don't really remember." When asked if she took the resident's vital signs she said, "I think so. If I did it would be in the nurses' notes." Review of nurses' notes for Resident #2 dated [DATE] revealed the only entries made were by LVN A. No assessment and no vital signs had been documented. During an interview on [DATE] at 1:00 p.m. with Resident #2's physician (facility's Medical Director) he said he was not notified on [DATE] of Resident #2's change of condition or that she was asking to go to the hospital. He said the facility protocol is to send residents to the ER for a change of condition or at the request of the resident. He said the facility should first notify the DON, then the primary physician (or the on- call physician). If a physician cannot be reached the facility knows to call him as, medical director. Review of the facility policy, Significant Change dated ,[DATE], revealed the following: "1. The nursing staff, as well as the interdisciplinary team, will evaluate the patient's/resident's change in status ... 2. The physician, legal representative or appropriate family member will be notified of the change in the patient/resident status when there is: A. An accident resulting in injury and the potential for medical intervention. B. A change in the patient's/resident's physical, mental or psychosocial status ... 3. All significant changes in a patient's/resident's condition will be relayed to the patient's/resident's physician immediately: * If the physician's office is closed, their service will be called; * If contact cannot be made, the Medical Director and Facility Administrator will be notified. * Attempts to reach the physician will continue until the physician is contacted. * All attempts to reach the physician should be thoroughly documented in the medical record." The IJ was called and facility administration was notified on [DATE] at 4:30 p.m. Facility's Plan to Remove Immediate Jeopardy: a) The Interim DON and ADONs will re-educate the licensed nurses regarding performing accurate assessments, documentation of assessments, notification of physician in change of condition, neurological checks and reporting changes in neurological condition during monitoring to the physician. This re-education will begin with the current shift (6:00 p.m. - 6:00 a.m. shift) on [DATE] and oncoming nurses at 5:00 a.m. will be re-educated prior to taking their assignments for their shift. This re-education process will continue throughout the weekend shifts to ensure that licensed nurses caring for the residents have been re-educated as above. A post test will validate staff understanding. The completion date for the re-education will be 6:00 a.m. on [DATE]. b) The Interim DON and ADONs will review the charts of residents with change of conditions to validate that the assessment has been performed, documented, notification of physician occurred, and neurological monitoring (if necessary) have been performed. This chart review will occur each day as part of the nursing leadership meeting Monday through Friday. The nurse managers on duty will check the 24 hour report for any new change of conditions and make observations of the resident to validate that the interventions have been appropriate and documentation reflects care delivered and condition of resident. **Refer to F-9999 for continuation of this deficiency.

Based on interviews and record reviews the facility failed to consult with residents' physicians for 2 of 4 residents reviewed (#1 and #2) that had a significant change of condition. The facility failed to: a) consult with Resident #1's physician (or physician on-call), when she had a fall on [DATE], sustained a head injury, and died on [DATE]; b) consult with Resident #2's physician on [DATE] when she developed nausea, vomiting, diarrhea, complained of abdominal pain, and was requesting to go to the hospital on [DATE]. She suffered a cardiac/respiratory arrest at the facility and died the same day. These failures resulted in an Immediate Jeopardy (IJ). The IJ was called on [DATE]. The immediacy was removed on [DATE]. The noncompliance continued at a level of pattern with actual harm that is not immediate jeopardy. Any of the 80 residents in the facility could be affected by these deficient practices. Failure to consult with a physician regarding an injury or a change in a resident's condition could result in negative resident outcomes due to not receiving appropriate medical interventions. Finding included: 1. Record review of Resident #1's Admission Record revealed Resident #1 was an [AGE] year old female, original admitted [DATE] with [DIAGNOSES REDACTED]. Record review of an incident report initiated and signed by LVN E dated [DATE] at 8:15 a.m. revealed that Resident #1 was in the bathroom; she lost her balance and fell , hitting the left side of her head on floor causing a five cm hematoma as well as two skin tears to her left hand. Skin tears measure 1.7 cm X 0.2 cm and 1.1 cm X 0.3cm. Resident #1 had full range of motion to all extremities; no other bruises or redness noted. Resident #1 complained of pain in head and neurological checks were initiated. LVN E wrote on the incident/accident report that she had notified Resident #1's PCP at 9:30 a.m. on [DATE]. Record review of incident investigation (undated) by Administrator and ADON 1 revealed the following: The investigation shows that [DATE] Housekeeper 1 witnessed Resident #1 fall on the morning of [DATE]. CNA E was making a bed. Housekeeper 1 was in the room, heard a 'thud', saw Resident #1 falling from the adjoining bathroom into room [ROOM NUMBER], hit her head on the dresser and continued to fall to the floor. Both CNA E and Housekeeper 1 tried to get to Resident #1, but were unable to because Resident #1's walker remained in the bathroom in front of the sink. CNA E moved it (the walker) out of the way to try to assist her, and then went to the door to call for help as Housekeeper 1 left the room to get help. All staff reported Resident #1 was trying to get up from the floor while they were assessing and monitoring her. Further review of the facility investigation revealed CNA F, LVN E, and CMA 1, entered the room. ADON 2, entered and noticed a skin tear on the resident's hand. Resident #1's right leg was "out of alignment" and ADON 2 evaluated and determined Resident #1 was able to move extremities within her normal abilities. A hematoma was noted on the left side toward the back of her head. Vital signs were taken while Resident #1 was still on the floor. There was no evidence of documentation in Resident #1's clinical record of the vital signs taken while the resident was on the floor. Further review of the facility investigation revealed Resident #1 was assisted up from the floor with a gait belt by CMA 1, LVN E and CNA F. Resident #1 ambulated to her room with assistance of staff and sat in her recliner. LVN E initiated neurological checks. Resident #1 was trying to get up from the recliner without assistance. Between (sic) LVN E and CMA 1 they remained in her room. LVN E continued neurological checks. Resident #1 was reportedly up most of night (Friday night) and slept most of day on Saturday. Sunday Resident #1 was back to ambulating between the lobby and her room. Review of Resident#1's clinical record revealed no evidence of documentation that the resident's PCP was notified of her change of condition. In an interview with ADON 2, on [DATE] at 3:25 p.m. he stated that on [DATE] between 8:00 a.m. and 8:30 a.m. he heard CNA E holler that someone was on the floor. He saw that the Resident #1 was on the floor with the top half of her body in room [ROOM NUMBER] and the lower half of her body in the adjoining restroom; the resident was trying to get up off of the floor. ADON 2 left to answer another resident's call light, came back to assist with Resident #1, and the other people in the room (CMA 1, LVN E, CNA F) were obtaining vital signs. ADON 2 said Resident #1 had a bump on back of her head; he heard the nurse say "hematoma". ADON 2 demonstrated to surveyors that the bump was about middle of the back of her head, "a small bump", about nickel sized, egg shaped, with no blood noted. ADON 2 noted skin tears to Resident #1's left hand, and was concerned that her right leg was "going outward". He was concerned about a possible [MEDICAL CONDITION]. After ascertaining Resident #1 was able to move the right leg, ADON 2 stated that he went back to his office. He said he did not get report on her vital signs and did not notify the resident's PCP. He said he did not feel that Resident #1 needed to be sent to the emergency room to be evaluated at that time. Review of the resident's clinical record revealed no evidence of documentation that ADON 2 notified Resident #1's PCP. In an interview with LVN E on [DATE] at 3:55 p.m. concerning Resident #1 falling on [DATE]; LVN E stated that she heard "a loud noise" and went into room [ROOM NUMBER] to find Resident #1 sitting on the floor in the doorway to the bathroom. She said she did a full head to toe assessment, that Resident #1 had full range of motion, noted a "knot" on the left side of her head and two skin tears to the left hand. LVN E stated that she gathered up all of her charting and took it to Resident #1's room to stay with her in order to "keep an eye on her", initiated neurological checks and an incident/accident report. LVN E stated that she spent most of the day in Resident #1's room. She and CNA E were talking about having pizza for lunch, Resident #1 overheard and wanted pizza also, and so LVN E and CNA E shared their pizza with Resident #1. LVN E stated that Resident #1 complained of a headache, so she gave her some Tylenol. LVN E stated that she received a call from the resident's PCP office nurse concerning another resident, and that she told the office nurse about Resident #1's fall. LVN E was not clear in this interview about what details she reported to the office nurse concerning Resident #1's fall or her condition following the fall. LVN E went on to state that she did notice that Resident #1's blood pressure was low in the beginning, but she does not remember if she reported it or not. LVN E stated she did not feel that Resident #1 needed to go to the emergency room to be evaluated at that time. Record review of physician order sheets dated [DATE] initiated by LVN C, revealed an order to clean Resident #1's skin tears with normal saline, apply TAO, and cover with a light dressing daily and as needed until healed. There was no evidence of any documentation of physician orders related to the 5 cm hematoma to the left side of Resident #1's head. Review of the neurological assessment sheet revealed blood pressure and pulse rates taken and recorded after the resident was moved from the floor to her recliner: [DATE]: 8:15 a.m. BP ,[DATE] (low), P 116 (high) 8:30 a.m. BP ,[DATE] (low), P 70; 8:45 a.m. BP ,[DATE], P 86; 10:00 a.m. ,[DATE] (high), P 68; 10:30 a.m. BP ,[DATE] (high), P 68; 12:00 noon BP ,[DATE] (high), P 76. [DATE]: 3:00 p.m. BP ,[DATE], P 74; [DATE]: (no time) BP ,[DATE], P 84. There was no evidence of documentation that any of these readings were communicated to Resident #1's PCP. Record review of Nurses' Notes dated [DATE] at 8:15 a.m. by LVN E revealed: "heard loud noise and found this resident on floor in doorway of bathroom, lost balance and fell - hit left side of head on floor causing five cm hematoma and two skin tears on left hand (1.7 cm X 0.2cm) and (1.1 cm X 0.3 cm), area cleansed with normal saline, triple antibiotic ointment and light dressing applied - Neurological checks initiated - full range of motion to all extremities; no other bruises or redness noted at this time, (ADON 1), PCP and family notified - sitting in recliner and up to bathroom several times with walker and assistance." There was no evidence of notation in Resident #1's clinical record concerning the initial low BP and elevated pulse rate being communicated to the PCP. Record review of Nurse's Notes dated [DATE] at 6:00 p.m. by LVN D revealed: "sitting in recliner. Resting; Complained of headache, took as needed dose of Tylenol 500 milligrams po given." Record review of a second Incident/Accident Investigation Worksheet dated [DATE] at 7:00 p.m. by LVN D revealed: "Resident fell in front lobby; witness by two aides..."paged MD on call - no response" (no time). Resident #1 was sent to a local hospital emergency room (ER) at 7:35 p.m. Record review of Nurses Notes dated [DATE] revealed that Resident #1's second fall occurred on [DATE] in the evening around 7 p.m. Resident #1 continued the same routine, ambulating to the lobby and back to the bathroom. Resident #1 was sitting in the green chair in the lobby, attempting to get up, and requested help. CNA C assisted her up and the resident ambulated toward the back of the couch, went to turn back toward the green chair after she complained of shortness of breath. CNA C was at Resident's # 1's side and called for CNA D's assistance as CNA C was attempting to get the resident seated. Resident #1 yelled, "I'm falling", then let go of her walker and fell backwards hitting her upper back on the shoulder of the couch. LVN D assessed Resident #1, noted an old purple bruise to left side of head (from the fall on Friday [DATE]). No other new bruises, hematomas or new skin tears were noted. Resident #1 complained of a headache and hurting all over. In an interview with CNA D on [DATE] at 10:35 a.m. he said for a couple of days before the second fall (on [DATE]) Resident #1 had been more confused than usual. He said she kept repeatedly asking for help to go to the bathroom. In an interview with CNA H on [DATE] at 2:53 p.m. she said she worked the two days after Resident #1's first fall ([DATE]). She said the resident was not eating (feeding herself) and had to be fed by staff at least one meal on Saturday ([DATE]). She said she noticed when the resident was in her recliner she was leaning 45 to 90 degrees to the left. In an interview with CNA G on [DATE] at 3:55 p.m. she said she has worked at this facility since ,[DATE] and has been a CNA since 1995. CNA G stated she was not working during either of Resident #2's falls, but did work Saturday [DATE], the day after the first fall, and Sunday [DATE]. CNA G went on to state that on that Saturday, Resident #1 stayed in her room, and slept most of day, which was very unusual for Resident #1, and Resident #1 stated "I don't feel good." CNA G stated that on Sunday [DATE] during the day Resident #1 was up and about in her usual manner, but was more confused than usual. Record review of the ER notes from local hospital dated [DATE] revealed that Resident #1 was agitated, repeatedly requested "help me, somebody please help me." Resident #1 complained of headache, blood pressure and heart rate elevated (initial BP ,[DATE], P 111 at 7:48 p.m.); at 8:20 p.m. Resident #1's BP was ,[DATE], no pulse rate recorded); pupils were sluggish and the resident needed to be restrained due to continued agitation. Record review of the Radiology and Nuclear Medicine reports from local hospital dated [DATE] at 7:59 p.m. revealed, "An acute 1.3 cm right sided subdural hematoma is seen with midline shift from right to left approximately 0.7 cm. Left parietal scalp swelling/hematoma is present. No underlying fractures identified. Mild cortical and cerebellar atrophy is present. Impression: "1. Acute right sided subdural hematoma with midline shift; 2. Left parietal soft tissue swelling." According to <http://www.medlineplus.com>: "An acute subdural hematoma (SDH) is a rapidly clotting blood collection below the inner layer of the dura but external to the brain and arachnoids' membrane. A subdural hematoma (SDH) is the most common type of intracranial mass lesion, occurring in about a third of those with severe head injuries. Subdural hematoma is more common in people older than [AGE] years. The elderly are predisposed to cerebral atrophy because they have less resilient bridging veins. Moreover, these veins can be damaged more easily in the elderly. Suspect acute subdural hematoma whenever the patient has experienced a mechanism of moderately severe to severe [MEDICATION NAME] head trauma." Record review of Physician's Progress notes from local hospital dated [DATE] at 9:50 p.m. by neurological admitting physician revealed, "Diagnosis: [REDACTED]." Record review from the Department of Radiology and Nuclear Medicine from local hospital dated [DATE] at 8:00 a.m. revealed "Impression: Significant enlargement of the patient's (Resident #1) right subdural hematoma..." Record review of the Progress Notes from local hospital dated [DATE] revealed: "Death Note...Time of death was at 1343 (1:43 p.m.)." In a telephone interview with Resident #1's physician office nurse on [DATE] at 10:42 a.m., she stated that the PCP was out of town from [DATE] to [DATE]. She said she checked all of the telephone logs for the PCP and the covering physician from that time period, particularly [DATE] when LVN E stated that she had notified the PCP's office. There was no evidence of any calls to or from the facility on [DATE]. In an interview with the facility's Medical Director on [DATE] at 1:00 p.m., he stated he was not notified of Resident #1's change of condition. He stated that the protocol was to send any resident to the emergency room at any time the resident requests, or at any time there is a change of condition. The Medical Director stated that the staff must notify the DON first, then the attending physician or the covering physician and if either physician were not available to call him (the facility Medical Director). During an interview with ADON 1 on [DATE] at 1:50 p.m. she said she was off on [DATE] when Resident #1 fell . She said the facility did not have a DON at that time and she (ADON 1) was not notified of the incident. She said, in hindsight, Resident #1 should have been sent to the ER for evaluation after falling and hitting her head. In a telephone interview with the Neurologist for Resident #1 on [DATE] at 5:05 p.m., he stated that when the resident was admitted to the hospital he was not aware that she had fallen and struck her head on [DATE]. He stated that through his record review and the condition of Resident #1's subdural hematoma, that the subdural hematoma likely occurred during the first fall on [DATE], especially since she did not strike her head during the second fall on [DATE]. The neurologist went on to state, "Any time any resident falls, whether it was a witnessed fall or an unwitnessed fall, if there is any suspicion the resident might have hit their head on anything, the resident needs to be evaluated immediately at the ER." 2. Record review of Resident #2's Admission Record revealed she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Her CPR status was Full Code. Record review of the MDS assessment dated [DATE] revealed her speech was clear, she was able to comprehend others, was able to express herself and make herself understood. She required extensive assistance of two people for bed mobility. She was not able to ambulate and was confined to the bed or wheelchair. She required extensive assistance for dressing toileting and bathing. She had an indwelling urinary catheter and a [MEDICAL CONDITION]. She was 4' 8" tall and weighed 68 lbs. Record review of the facility's investigation report by ADON 1 dated [DATE] revealed the following: `1) At approximately 1:30 p.m. CNA A and CNA B came to her office and reported that the charge nurse (LVN A) was aware that Resident #2 wanted to go to the hospital, she had been sick all day, and just wasn't acting right. After being notified of this, ADON 1 documented that she and the Administrator called LVN A into the office to speak with her. The interview revealed that she was aware of Resident #2 vomiting, her complaints of stomach pain, and not feeling well. LVN A was also aware of the resident's requests to go to the hospital, but could not explain why she did not send the resident to the hospital. 2) LVN A documented that a fax was sent (no time noted) to Resident #2's physician concerning her vomiting and requesting some other medication besides [MEDICATION NAME] for this. This physician requests all faxes to be placed in his box at the facility and he addresses them when he comes in to make rounds, which is usually after lunch, and LVN A was aware of this. LVN A did not call the Resident's physician regarding her change of condition. 3) LVN A documented in the nurses' notes that Resident #2 had vomited in the dining room, but investigation revealed the resident did not get out of bed that morning. Breakfast had been brought to her room but she refused everything except cream of wheat. CNA A was monitoring the hall while CNA B was feeding residents' breakfast in the dining room. At approximately 8:15 a.m. LVN A went to the dining room to get CNA B to go assist CNA A to clean up Resident #2 after she had an episode of vomiting. Both CNA A and CNA B reported to LVN A that the resident had complained of not feeling well, complained of stomach pain, did not look well and had slurred speech. 4) LVN B (medication nurse) went to Resident #2's room (no time noted) to give her a pain pill ([MEDICATION NAME]) which she refused at that time because of nausea and vomiting. LVN B gave the resident [MEDICATION NAME]. 5) At approximately 9:00 a.m. CNA A, CNA B, and LVN C (treatment nurse) were in Resident #2's room, changing her [MEDICAL CONDITION] bag after an episode of diarrhea. LVN A came into the room and CNA B was talking to the resident, and the resident was saying she wanted to go to the hospital. LVN C said she did not hear her say that but did say the resident "did not look right". LVN C said she asked the resident what was wrong and the resident said she didn't know but something was not right, but could not explain what. LVN C left the room and thought that LVN A would call the doctor. LVN C said she was not aware Resident #2's physician was not notified until after the resident had coded. 6) LVN A said Resident #2 turned on her call light (no time noted). When she went to the resident's room she was short of breath, her O2 sats were in the 90's (normal) so she elevated the head of the bed. The oxygen was continuous and was in place. LVN A said the resident acted like she wanted to get out of bed. As LVN A was leaving the room she saw CNA B as she was taking a resident to the dining room for lunch and told her go ahead and get Resident #2 up for lunch, it might help her stomach. 7) CNA B went to Resident #2's room then left to get a washcloth (no time noted). She told LVN A that the Resident did not look good. CNA B returned to the resident's room and found her with her eyes wide open and her left arm shaking. CNA B summoned LVN A. LVN A was unable to get a blood pressure on the resident. ADON 1 was summoned. She found the resident unresponsive, pupils fixed and dilated, with no pulse or blood pressure. CPR was initiated and 911 was called. Fluids kept coming from the resident's mouth requiring her to be suctioned intermittently. The fire department arrived and took over CPR. The ambulance arrived and the resident was taken to the ER. Record review of the Provider Investigation Report dated [DATE] revealed Resident #2 had a history of [REDACTED]. The incident occurred on [DATE]. Under Description of the Allegation it was documented that the resident had nausea and vomiting and requested to go to the hospital. Resident was given [MEDICATION NAME] (a medication for indigestion) and [MEDICATION NAME] (a pain medication). Resident was found unresponsive at 10:50 a.m. Under Description of Injury it was documented that the resident was found unresponsive with no pulse or blood pressure. Her pupils were fixed and dilated. Under Description of Assessment it was documented that vital signs were assessed and CPR initiated. Under Provider Response it was documented that the initial assessment was incomplete because resident request was not honored and physician not notified of change in condition. Record review of the nurses' notes revealed the following entry on [DATE] by LVN A: (No time entered) "Resident up in w/c to D/R for breakfast. Started c/o stomach hurting. [MEDICATION NAME] 30cc P.O. given for discomfort. Vomited small amt. emesis - Resident put back to bed. Positioned on left side - [MEDICAL CONDITION] bag changed, had loose stool." "0930 (9:30 a.m.) C/o stomach still hurting. [MEDICATION NAME] 1 p.o. given (50 mg)." (No time entered) "ADLs done by staff - Foley catheter patent ..." (No time entered) "Fax to Dr.___ about vomiting ask for something else besides [MEDICATION NAME]." Review of a fax to Dr. ___ dated [DATE] (no time) revealed the following: " *comments: (Resident #2) Resident vomited x1 at breakfast table - brought back to room [MEDICATION NAME] was given still complained of pain [MEDICATION NAME] 50 mg 1 p.o. given - Resident had loose stool - [MEDICAL CONDITION] bag was changed. Resident confused at times - Could we have something else for nausea besides [MEDICATION NAME]" Further review of nurses' notes dated [DATE] by LVN A revealed the following: "1050 (10:50 a.m.) Resident sleeping appears to be resting comfortably...resident turned on call light when nurse went to room resident was talking - stated she was SOB. - O2 sat. 98% HOB (elevated) when nurse asked if she wanted to sit up in w/c she acted as if she was going to get out of bed - Ask CNA to help her get up - when CNA entered room resident was not responding - pupils were dilated - Crash cart was brought to room and 911 called. CPR initiated by (ADON 1) and (ADON 2) - Resident vomited large amount brown liquid. Resident suctioned obtained small amt brown liquid - 02 via nasal cannula at 3 LPM - Resident still unresponsive. " "1115 (11:15 a.m.) ___ Ambulance here CPR administered by ___ Ambulance - unable to obtain heart beat. Resident transferred to (hospital)." Review of the hospital emergency room records revealed Resident #2 arrived in theER on [DATE] at 11:35 a.m. with CPR still in progress. The ER physician and staff were unable to revive Resident #2 and she died . Her death was pronounced at 11:46 a.m. During an interview with LVN B on [DATE] at 11:25 a.m. she said she was told on [DATE], around breakfast time, by LVN A that Resident #2 needed something for pain. She said she took the resident an [MEDICATION NAME] but the resident said she couldn't take it because she was nauseated. LVN B said she gave her [MEDICATION NAME] instead at that time and returned later and gave her the [MEDICATION NAME]. LVN B said she started working at the facility a couple of months ago on a prn basis. She said they call her to work if someone calls in. She said she thought [DATE] was only her second time to work in the facility and said she "really didn't know these residents." LVN B did not assess the resident and did not notify the resident ' s physician of her change of condition. During an interview with CNA A on [DATE] at 11:35 a.m. she said Resident #2 didn't want to get up for breakfast that morning ([DATE]). She said she took her breakfast tray to her room but she didn't want anything. She said she was passing the other hall trays when the med nurse (LVN B) told her that Resident #2 had vomited. She said she got CNA B to help her clean up the resident. She said Resident #2 was asking to see the doctor or to go to the hospital. She said as the morning went on she "just wasn't herself." She complained of aching and having mid-abdominal pain. She said "she was not as talkative as usual and was more withdrawn, and she just kept saying she hurt and needed to see the doctor." She said LVN A was aware that Resident #2 was asking to go to the hospital. During an interview on [DATE] at 2:10 p.m. ADON 1 said she was in charge at the facility on [DATE]. She said she was unaware of Resident #2's change of condition or her requests to be sent to the hospital that morning. She said when she responded to the code, Resident #2 was not breathing and had no blood pressure or pulse. She said she initiated CPR and had 911 called. She said they had to interrupt CPR several times to suction dark brown fluid from the resident's mouth. ADON 1 said that her investigation revealed that no one (LVN A, B or C) had notified Resident #2's physician of her change of condition or her requests to be sent to the hospital. She said LVN A had just put a fax in the doctor's box asking for something besides [MEDICATION NAME] for her nausea and vomiting. During an interview with LVN A on [DATE] at 4:30 p.m. she said that on [DATE] around 8:30 a.m. she was told by CNA B that Resident #2 had vomited. She said she asked LVN B (medication nurse) if she had given the resident anything for nausea and that LVN B said she had given her [MEDICATION NAME]. LVN A said she went to the resident's room to check on her and the resident said her stomach was hurting. She had diarrhea in her [MEDICAL CONDITION] bag. LVN A said the resident settled down for a little while but was woke up by hammering in a nearby room that was being renovated. She put on her call light and said she was not feeling good. LVN A said she had faxed the doctor and he would see her when he made rounds. She said Resident #2 did ask to go the hospital but she had only vomited once. She said Resident #2 had so many things wrong with her it was sometimes hard to know what was going on with her. When asked if she assessed the resident that morning she said, "I looked at her, but I don't really remember." When asked if she took the resident's vital signs she said, "I think so. If I did it would be in the nurses' notes." Review of nurses' notes for Resident #2 dated [DATE] revealed the only entries made were by LVN A. No assessment and no vital signs had been documented. During an interview on [DATE] at 1:00 p.m. with Resident #2's physician (facility's Medical Director) he said he was not notified on [DATE] of Resident #2's change of condition or that she was asking to go to the hospital. He said the facility protocol is to send residents to the ER for a change of condition or at the request of the resident. He said the facility should first notify the DON, then the primary physician (or the on- call physician). If a physician cannot be reached the facility knows to call him as, medical director. Review of the facility policy, Significant Change dated ,[DATE], revealed the following: "1. The nursing staff, as well as the interdisciplinary team, will evaluate the patient's/resident's change in status ... 2. The physician, legal representative or appropriate family member will be notified of the change in the patient/resident status when there is: A. An accident resulting in injury and the potential for medical intervention. B. A change in the patient's/resident's physical, mental or psychosocial status ... 3. All significant changes in a patient's/resident's condition will be relayed to the patient's/resident's physician immediately: * If the physician's office is closed, their service will be called; * If contact cannot be made, the Medical Director and Facility Administrator will be notified. * Attempts to reach the physician will continue until the physician is contacted. * All attempts to reach the physician should be thoroughly documented in the medical record." The IJ was called and facility administration was notified on [DATE] at 4:30 p.m. Facility's Plan to Remove Immediate Jeopardy: a) The Interim DON and ADONs will re-educate the licensed nurses regarding performing accurate assessments, documentation of assessments, notification of physician in change of condition, neurological checks and reporting changes in neurological condition during monitoring to the physician. This re-education will begin with the current shift (6:00 p.m. - 6:00 a.m. shift) on [DATE] and oncoming nurses at 5:00 a.m. will be re-educated prior to taking their assignments for their shift. This re-education process will continue throughout the weekend shifts to ensure that licensed nurses caring for the residents have been re-educated as above. A post test will validate staff understanding. The completion date for the re-education will be 6:00 a.m. on [DATE]. b) The Interim DON and ADONs will review the charts of residents with change of conditions to validate that the assessment has been performed, documented, notification of physician occurred, and neurological monitoring (if necessary) have been performed. This chart review will occur each day as part of the nursing leadership meeting Monday through Friday. The nurse managers on duty will check the 24 hour report for any new change of conditions and make observations of the resident to validate that the interventions have been appropriate and documentation reflects care delivered and condition of resident. c) The Interim DON or designee will review incidents and investigations for appropriate follow-up and interventions Monday through Friday as part of nursing leadership meeting. d) The Performance Improvement Committee will review the results of audits for trends, patterns and concerns monthly. On [DATE] the surveyors confirmed through interviews and record reviews: a) Nursing staff had been re-educated on performing accurate assessments, documentation of assessments, notification of physician in change of condition, neurological checks and reporting changes in neurological condition during monitoring to the physician. Nursing staff in-services were conducted on [DATE] at 5:00 a.m. and 5:00 p.m. and on [DATE] at 5:00 p.m.; b) Charts of residents with change of conditions were being reviewed to validate that assessments had been performed, documented, notification of physician occurred, and neurological monitoring (if necessary) had been performed. Observations of the residents were made by nurse managers to validate that the interventions were appropriate and documentation reflected care delivered and condition of resident; c) Incidents and investigations were being reviewed by nurse managers for appropriate follow-up and interventions. The immediacy was removed on [DATE] at 3:30 p.m. The facility remained out of compliance at the level of pattern with actual harm that is not immediate jeopardy because they had not yet monitored or evaluated the action plan for effectiveness. Review of the CMS 672, Resident Census and Conditions of Residents, dated [DATE] revealed a facility census of 80 residents.

Based on interviews and record reviews the facility failed to ensure that services provided met professional standards of quality. Facility licensed nurses failed to ensure 2 of 4 reviewed residents (#1 and #2) were provided the services necessary to avoid physical harm, mental anguish and death as evidenced by: a) failure to thoroughly assess Resident #1 and consult with her physian (or physician on-call), after the resident fell and sustained a head injury on [DATE]. The resident died on [DATE]. b) failure to assess and consult with Resident #2's physician on [DATE] when she developed nausea, vomiting, diarrhea, complained of abdominal pain, and was requesting to go to the hospital. Resident #2 suffered a cardiac/respiratory arrest at the facility and was pronounced dead in the ER later that same morning. These failures resulted in an Immediate Jeopardy (IJ). The IJ was called on [DATE]. The immediacy was removed prior to exit on [DATE]. The noncompliance continued at a level of pattern with actual harm that is not immediate jeopardy. Any of the 80 residents in the facility could be affected by these deficient practices. Failure to assess residents' and consult with a physician regarding an injury or a change of condition could result in negative resident outcomes, including death, due to not receiving appropriate medical interventions. Finding included: 1. The Texas Board of Nursing, Rule # 217.11 Standards of Nursing Practice, includes the following: 1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;............... (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status;........ Record review of Resident #1's Admission Record revealed Resident #1 was an [AGE] year old female, original admitted [DATE] with [DIAGNOSES REDACTED]. Record review of an incident report initiated and signed by LVN E dated [DATE] at 8:15 a.m. revealed that Resident #1 was in the bathroom; she lost her balance and fell , hitting the left side of her head on floor causing a five cm hematoma as well as two skin tears to her left hand. Skin tears measure 1.7 cm X 0.2 cm and 1.1 cm X 0.3cm. Resident #1 had full range of motion to all extremities; no other bruises or redness noted. Resident #1 complained of pain in head and neurological checks were initiated. LVN E wrote on the incident/accident report that she had notified Resident #1's PCP at 9:30 a.m. on [DATE]. Record review of incident investigation (undated) by Administrator and ADON 1 revealed the following: The investigation shows that Housekeeper 1 witnessed Resident#1 fall on the morning of [DATE]. CNA E was making a bed. Housekeeper 1 was in the room, heard a 'thud', saw Resident #1 falling from the adjoining bathroom into room [ROOM NUMBER], hit her head on the dresser and continued to fall to the floor. Both CNA E and Housekeeper 1 tried to get to Resident #1, but were unable to because Resident #1's walker was in the bathroom in front of the sink. CNA E moved it (the walker) out of the way to try to assist her, and then went to the door to call for help as Housekeeper 1 left the room to get help. All staff reported Resident #1 was trying to get up from the floor while they were assessing and monitoring her. Further review of the facility investigation revealed CNA F, LVN E, and CMA 1, entered the room. ADON 2, entered and noticed a skin tear on the resident's hand. Resident #1's right leg was "out of alignment" and ADON 2 evaluated and determined Resident #1 was able to move extremities within her normal abilities. A hematoma was noted on the left side toward the back of her head. Vital signs were taken while Resident #1 was still on the floor. There was no evidence of documentation in Resident #1's clinical record of the vital signs taken while the resident was on the floor. Further review of the facility investigation revealed Resident #1 was assisted up from the floor with a gait belt by CMA 1, LVN E and CNA F. Resident #1 ambulated to her room with assistance of staff and sat in her recliner. LVN E initiated neurological checks. Resident #1 was trying to get up from the recliner without assistance. Between (sic) LVN E and CMA 1 they remained in her room. LVN E continued neurological checks. Resident #1 was reportedly up most of night (Friday night) and slept most of day on Saturday. Sunday Resident #1 was back to ambulating between the lobby and her room. Review of Resident#1's clinical record revealed no evidence of documentation that the resident's PCP was notified of her change of condition. In an interview with ADON 2, on [DATE] at 3:25 p.m. he stated that on [DATE] between 8:00 a.m. and 8:30 a.m. he heard CNA E holler that someone was on the floor. He saw that the Resident #1 was on the floor with the top half of her body in room [ROOM NUMBER] and the lower half of her body in the adjoining restroom; the resident was trying to get up off of the floor. ADON 2 left to answer another resident's call light, came back to assist with Resident #1, and the other people in the room (CMA 1, LVN E, CNA F) were obtaining vital signs. ADON 2 said Resident #1 had a bump on back of her head; he heard the nurse say "hematoma". ADON 2 demonstrated to surveyors that the bump was about middle of the back of her head, "a small bump", about nickel sized, egg shaped, with no blood noted. ADON 2 noted skin tears to Resident #1's left hand, and was concerned that her right leg was "going outward". He was concerned about a possible [MEDICAL CONDITION]. After ascertaining Resident #1 was able to move the right leg, ADON 2 stated that he went back to his office. He said he did not get report on her vital signs and did not notify the resident's PCP. He said he did not feel that Resident #1 needed to be sent to the emergency room to be evaluated at that time. Review of the resident's clinical record revealed no evidence of documentation that ADON 2 notified Resident #1's PCP. In an interview with LVN E on [DATE] at 3:55 p.m. concerning Resident #1 falling on [DATE]; LVN E stated that she heard "a loud noise" and went into room [ROOM NUMBER] to find Resident #1 sitting on the floor in the doorway to the bathroom. She said she did a full head to toe assessment, that Resident #1 had full range of motion, noted a "knot" on the left side of her head and two skin tears to the left hand. LVN E stated that she gathered up all of her charting and took it to Resident #1's room to stay with her in order to "keep an eye on her", initiated neurological checks and an incident/accident report. LVN E stated that she spent most of the day in Resident #1's room. She and CNA E were talking about having pizza for lunch, Resident #1 overheard and wanted pizza also, and so LVN E and CNA E shared their pizza with Resident #1. LVN E stated that Resident #1 complained of a headache, so she gave her some Tylenol. LVN E stated that she received a call from the resident's PCP office nurse concerning another resident and LVN E told the office nurse about Resident #1's fall. LVN E was not clear in this interview about what details she reported to the office nurse concerning Resident #1's fall or her condition following the fall. LVN E went on to state that she did notice that Resident #1's blood pressure was low in the beginning, but she does not remember if she reported it or not. LVN E stated she did not feel that Resident #1 needed to go to the emergency room to be evaluated at that time. Record review of physician order sheets dated [DATE] initiated by LVN C, revealed an order to clean Resident #1's skin tears with normal saline, apply TAO, and cover with a light dressing daily and as needed until healed. There was no evidence of any documentation of physician orders related to the 5 cm hematoma to the left side of Resident #1's head. Review of the neurological assessment sheet revealed blood pressure and pulse rates taken and recorded after Resident #1 was moved from the floor to her recliner: [DATE]: 8:15 a.m. BP ,[DATE] (low), P 116 (high) 8:30 a.m. BP ,[DATE] (low), P 70; 8:45 a.m. BP ,[DATE], P 86; 10:00 a.m. ,[DATE] (high), P 68; 10:30 a.m. BP ,[DATE] (high), P 68; 12:00 noon BP ,[DATE] (high), P 76. [DATE]: 3:00 p.m. BP ,[DATE], P 74; [DATE]: (no time) BP ,[DATE], P 84. There was no evidence of documentation that any of these readings were communicated to Resident #1's PCP. Record review of Nurses' Notes dated [DATE] at 8:15 a.m. by LVN E revealed: "heard loud noise and found this resident on floor in doorway of bathroom, lost balance and fell - hit left side of head on floor causing five cm hematoma and two skin tears on left hand (1.7 cm X 0.2cm) and (1.1 cm X 0.3 cm), area cleansed with normal saline, triple antibiotic ointment and light dressing applied - Neurological checks initiated - full range of motion to all extremities; no other bruises or redness noted at this time, (ADON 1), PCP and family notified - sitting in recliner and up to bathroom several times with walker and assistance." There was no evidence of notation about the initial low BP and elevated pulse rate being communicated to the PCP. Record review of Nurse's Notes dated [DATE] at 6:00 p.m. by LVN D revealed: "sitting in recliner. Resting; Complained of headache, took as needed dose of Tylenol 500 milligrams po given." Record review of a second Incident/Accident Investigation Worksheet dated [DATE] at 7:00 p.m. by LVN D revealed: "Resident fell in front lobby; witness by two aides..."paged MD on call - no response" (no time). Resident #1 was sent to a local hospital emergency room (ER) at 7:35 p.m. Record review of Nurses Notes dated [DATE] revealed that Resident #1's second fall occurred on [DATE] in the evening around 7 p.m. Resident #1 continued the same routine, ambulating to the lobby and back to the bathroom. Resident #1 was sitting in the green chair in the lobby, attempting to get up, and requested help. CNA C assisted her up and the resident ambulated toward the back of the couch, went to turn back toward the green chair after she complained of shortness of breath. CNA C was at Resident's # 1's side and called for CNA D's assistance as CNA C was attempting to get the resident seated. Resident #1 yelled, "I'm falling", then let go of her walker and fell backwards hitting her upper back on the shoulder of the couch. LVN D assessed Resident #1, noted an old purple bruise to left side of head (from the fall on Friday [DATE]). No other new bruises, hematomas or new skin tears were noted. Resident #1 complained of a headache and hurting all over. In an interview with CNA D on [DATE] at 10:35 a.m. he said for a couple of days before the second fall (on [DATE]) Resident #1 had been more confused than usual. He said she kept repeatedly asking for help to go to the bathroom. In an interview with CNA H on [DATE] at 2:53 p.m. she said she worked the two days after Resident #1's first fall ([DATE]). She said the resident was not eating (feeding herself) and had to be fed by staff at least one meal on Saturday ([DATE]). She said she noticed when the resident was in her recliner she was leaning 45 to 90 degrees to the left. In an interview with CNA G on [DATE] at 3:55 p.m. she said she has worked at this facility since ,[DATE] and has been a CNA since 1995. CNA G stated she was not working during either of Resident #2's falls, but did work Saturday [DATE], the day after the first fall, and Sunday [DATE]. CNA G went on to state that on that Saturday, Resident #1 stayed in her room, and slept most of day, which was very unusual for Resident #1, and Resident #1 stated "I don't feel good." CNA G stated that on Sunday [DATE] during the day Resident #1 was up and about in her usual manner, but was more confused than usual. Record review of the ER notes from local hospital dated [DATE] revealed that Resident #1 was agitated, repeatedly requested "help me, somebody please help me." Resident #1 complained of headache, blood pressure and heart rate elevated (initial BP ,[DATE], P 111 at 7:48 p.m.); at 8:20 p.m. Resident #1's BP was ,[DATE], no pulse rate recorded); pupils were sluggish and the resident needed to be restrained due to continued agitation. Record review of the Radiology and Nuclear Medicine reports from local hospital dated [DATE] at 7:59 p.m. revealed, "An acute 1.3 cm right sided subdural hematoma is seen with midline shift from right to left approximately 0.7 cm. Left parietal scalp swelling/hematoma is present. No underlying fractures identified. Mild cortical and cerebellar atrophy is present. Impression: "1. Acute right sided subdural hematoma with midline shift; 2. Left parietal soft tissue swelling." According to <http://www.medlineplus.com>: "An acute subdural hematoma (SDH) is a rapidly clotting blood collection below the inner layer of the dura but external to the brain and arachnoids' membrane. A subdural hematoma (SDH) is the most common type of intracranial mass lesion, occurring in about a third of those with severe head injuries. Subdural hematoma is more common in people older than [AGE] years. The elderly are predisposed to cerebral atrophy because they have less resilient bridging veins. Moreover, these veins can be damaged more easily in the elderly. Suspect acute subdural hematoma whenever the patient has experienced a mechanism of moderately severe to severe [MEDICATION NAME] head trauma." Record review of Physician's Progress notes from local hospital dated [DATE] at 9:50 p.m. by neurological admitting physician revealed, "Diagnosis: [REDACTED]." Record review from the Department of Radiology and Nuclear Medicine from local hospital dated [DATE] at 8:00 a.m. revealed: "Impression: Significant enlargement of the patient's (Resident #1) right subdural hematoma..." Record review of the Progress Notes from local hospital dated [DATE] revealed: "Death Note...Time of death was at 1343 (1:43 p.m.)." In a telephone interview with Resident #1's physician office nurse on [DATE] at 10:42 a.m., she stated that the PCP was out of town from [DATE] to [DATE]. She said she checked all of the telephone logs for the PCP and the covering physician from that time period, particularly [DATE] when LVN E stated that she had notified the PCP's office. There was no evidence of any calls to or from the facility on [DATE]. In an interview with the facility's Medical Director on [DATE] at 1:00 p.m., he stated he was not notified of Resident #1's change of condition. He stated that the protocol was to send any resident to the emergency room at any time the resident requests, or at any time there is a change of condition. The Medical Director stated that the staff must notify the DON first, then the attending physician or the covering physician and if either physician were not available to call him (the facility Medical Director). During an interview with ADON 1 on [DATE] at 1:50 p.m. she said she was off on [DATE] when Resident #1 fell . She said the facility did not have a DON at that time and she (ADON 1) was not notified of the incident. She said, in hindsight, Resident #1 should have been sent to the ER for evaluation after falling and hitting her head. In a telephone interview with the Neurologist for Resident #1 on [DATE] at 5:05 p.m., he stated that when the resident was admitted to the hospital he was not aware that she had fallen and struck her head on [DATE]. He stated that through his record review and the condition of Resident #1's subdural hematoma, that the subdural hematoma likely occurred during the first fall on [DATE], especially since she did not strike her head during the second fall on [DATE]. The neurologist went on to state, "Any time any resident falls, whether it was a witnessed fall or an unwitnessed fall, if there is any suspicion the resident might have hit their head on anything, the resident needs to be evaluated immediately at the ER." 2. Record review of Resident #2's Admission Record revealed she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Her CPR status was Full Code. Record review of the MDS assessment dated [DATE] revealed her speech was clear, she was able to comprehend others, was able to express herself and make herself understood. She required extensive assistance of two people for bed mobility. She was not able to ambulate and was confined to the bed or wheelchair. She required extensive assistance for dressing toileting and bathing. She had an indwelling urinary catheter and a [MEDICAL CONDITION]. She was 4' 8" tall and weighed 68 lbs. Record review of the facility's investigation report by ADON 1 dated [DATE] revealed the following: 1) At approximately 1:30 p.m. CNA A and CNA B came to her office and reported that the charge nurse (LVN A) was aware that Resident #2 wanted to go to the hospital, she had been sick all day, and just wasn't acting right. After being notified of this, ADON 1 documented that she and the Administrator called LVN A into the office to speak with her. The interview revealed that she was aware of Resident #2 vomiting, her complaints of stomach pain, and not feeling well. LVN A was also aware of the resident's requests to go to the hospital, but could not explain why she did not send the resident to the hospital. 2) LVN A documented that a fax was sent (no time noted) to Resident #2's physician concerning her vomiting and requesting some other medication besides [MEDICATION NAME] for this. This physician requests all faxes to be placed in his box at the facility and he addresses them when he comes in to make rounds, which is usually after lunch, and LVN A was aware of this. LVN A did not call the Resident's physician regarding her change of condition. 3) LVN A documented in the nurses' notes that Resident #2 had vomited in the dining room, but investigation revealed the resident did not get out of bed that morning. Breakfast had been brought to her room but she refused everything except cream of wheat. CNA A was monitoring the hall while CNA B was feeding residents' breakfast in the dining room. At approximately 8:15 a.m. LVN A went to the dining room to get CNA B to go assist CNA A to clean up Resident #2 after she had an episode of vomiting. Both CNA A and CNA B reported to LVN A that the resident had complained of not feeling well, complained of stomach pain, did not look well and had slurred speech. 4) LVN B (medication nurse) went to Resident #2's room (no time noted) to give her a pain pill ([MEDICATION NAME]) which she refused at that time because of nausea and vomiting. LVN B gave the resident [MEDICATION NAME]. 5) At approximately 9:00 a.m. CNA A, CNA B, and LVN C (treatment nurse) were in Resident #2's room, changing her [MEDICAL CONDITION] bag after an episode of diarrhea. LVN A came into the room and CNA B was talking to the resident, and the resident was saying she wanted to go to the hospital. LVN C said she did not hear her say that but did say the resident "did not look right". LVN C said she asked the resident what was wrong and the resident said she didn't know but something was not right, but could not explain what. LVN C left the room and thought that LVN A would call the doctor. LVN C said she was not aware Resident #2's physician was not notified until after the resident had coded. 6) LVN A said Resident #2 (no time noted) turned on her call light. When she went to the resident's room she was short of breath, her O2 sats were in the 90's (normal) so she elevated the head of the bed. The oxygen was continuous and was in place. LVN A said the resident acted like she wanted to get out of bed. As LVN A was leaving the room she saw CNA B as she was taking a resident to the dining room for lunch and told her go ahead and get Resident #2 up for lunch, it might help her stomach. 7) CNA B went to Resident #2's room then left to get a washcloth (no time noted). She told LVN A that the Resident did not look good. CNA B returned to the resident's room and found her with her eyes wide open and her left arm shaking. CNA B summoned LVN A. LVN A was unable to get a blood pressure on the resident. ADON 1 was summoned. She found the resident unresponsive, pupils fixed and dilated, with no pulse or blood pressure. CPR was initiated and 911 was called. Fluids kept coming from the resident's mouth requiring her to be suctioned intermittently. The fire department arrived and took over CPR. The ambulance arrived and the resident was taken to the ER. Record review of the Provider Investigation Report dated [DATE] revealed Resident #2 had a history of [REDACTED]. The incident occurred on [DATE]. Under Description of the Allegation it was documented that the resident had nausea and vomiting and requested to go to the hospital. Resident was given [MEDICATION NAME] (a medication for indigestion) and [MEDICATION NAME] (a pain medication). Resident was found unresponsive at 10:50 a.m. Under Description of Injury it was documented that the resident was found unresponsive with no pulse or blood pressure. Her pupils were fixed and dilated. Under Description of Assessment it was documented that vital signs were assessed and CPR initiated. Under Provider Response it was documented that the initial assessment was incomplete because resident request was not honored and physician not notified of change in condition. Record review of the nurses' notes revealed the following entry on [DATE] by LVN A: (No time entered) "Resident up in w/c to D/R for breakfast. Started c/o stomach hurting. [MEDICATION NAME] 30cc P.O. given for discomfort. Vomited small amt. emesis - Resident put back to bed. Positioned on left side - [MEDICAL CONDITION] bag changed, had loose stool." "0930 (9:30 a.m.) C/o stomach still hurting. [MEDICATION NAME] 1 p.o. given (50 mg)." (No time entered) "ADLs done by staff - Foley catheter patent ..." (No time entered) "Fax to Dr.___ about vomiting ask for something else besides [MEDICATION NAME]." Review of a fax to Dr. ___ dated [DATE] (no time) revealed the following: " *comments: (Resident #2) Resident vomited x1 at breakfast table - brought back to room [MEDICATION NAME] was given still complained of pain [MEDICATION NAME] 50 mg 1 p.o. given - Resident had loose stool - [MEDICAL CONDITION] bag was changed. Resident confused at times - Could we have something else for nausea besides [MEDICATION NAME]" Further review of nurses' notes dated [DATE] by LVN A revealed the following: "1050 (10:50 a.m.) Resident sleeping appears to be resting comfortably...resident turned on call light when nurse went to room resident was talking - stated she was SOB. - O2 sat. 98% HOB (elevated) when nurse asked if she wanted to sit up in w/c she acted as if she was going to get out of bed - Ask CNA to help her get up - when CNA entered room resident was not responding - pupils were dilated - Crash cart was brought to room and 911 called. CPR initiated by (ADON 1) and (ADON 2) - Resident vomited large amount brown liquid. Resident suctioned obtained small amt brown liquid - 02 via nasal cannula at 3 LPM - Resident still unresponsive. " "1115 (11:15 a.m.) ___ Ambulance here CPR administered by ___ Ambulance - unable to obtain heart beat. Resident transferred to (hospital)." Review of the hospital emergency room records revealed Resident #2 arrived in theER on [DATE] at 11:35 a.m. with CPR still in progress. The ER physician and staff were unable to revive Resident #2 and she died . Her death was pronounced at 11:46 a.m. During an interview with LVN B on [DATE] at 11:25 a.m. she said she was told on [DATE], around breakfast time, by LVN A that Resident #2 needed something for pain. She said she took the resident an [MEDICATION NAME] but the resident said she couldn't take it because she was nauseated. LVN B said she gave her [MEDICATION NAME] instead at that time and returned later and gave her the [MEDICATION NAME]. LVN B said she started working at the facility a couple of months ago on a prn basis. She said they call her to work if someone calls in. She said she thought [DATE] was only her second time to work in the facility and said she "really didn't know these residents." LVN B did not assess the resident and did not notify the resident ' s physician of her change of condition. During an interview with CNA A on [DATE] at 11:35 a.m. she said Resident #2 didn't want to get up for breakfast that morning ([DATE]). She said she took her breakfast tray to her room but she didn't want anything. She said she was passing the other hall trays when the med nurse (LVN B) told her that Resident #2 had vomited. She said she got CNA B to help her clean up the resident. She said Resident #2 was asking to see the doctor or to go to the hospital. She said as the morning went on she "just wasn't herself." She complained of aching and having mid-abdominal pain. She said "she was not as talkative as usual and was more withdrawn, and she just kept saying she hurt and needed to see the doctor." She said LVN A was aware that Resident #2 was asking to go to the hospital. During an interview on [DATE] at 2:10 p.m. ADON 1 said she was in charge at the facility on [DATE]. She said she was unaware of Resident #2's change of condition or her requests to be sent to the hospital that morning. She said when she responded to the code, Resident #2 was not breathing and had no blood pressure or pulse. She said she initiated CPR and had 911 called. She said they had to interrupt CPR several times to suction dark brown fluid from the resident's mouth. ADON 1 said that her investigation revealed that no one (LVN A, B or C) had notified Resident #2's physician of her change of condition or her requests to be sent to the hospital. She said LVN A had just put a fax in the doctor's box asking for something besides [MEDICATION NAME] for her nausea and vomiting. During an interview with LVN A on [DATE] at 4:30 p.m. she said that on [DATE] around 8:30 a.m. she was told by CNA B that Resident #2 had vomited. She said she asked LVN B (medication nurse) if she had given the resident anything for nausea and that LVN B said she had given her [MEDICATION NAME]. LVN A said she went to the resident's room to check on her and the resident said her stomach was hurting. She had diarrhea in her [MEDICAL CONDITION] bag. LVN A said the resident settled down for a little while but was woke up by hammering in a nearby room that was being renovated. She put on her call light and said she was not feeling good. LVN A said she had faxed the doctor and he would see her when he made rounds. She said Resident #2 did ask to go the hospital but she had only vomited once. She said Resident #2 had so many things wrong with her it was sometimes hard to know what was going on with her. When asked if she assessed the resident that morning she said, "I looked at her, but I don't really remember." When asked if she took the resident's vital signs she said, "I think so. If I did it would be in the nurses' notes." Review of nurses' notes for Resident #2 dated [DATE] revealed the only entries made were by LVN A. No assessment and no vital signs had been documented. During an interview on [DATE] at 1:00 p.m. with Resident #2's physician (facility's Medical Director) he said he was not notified on [DATE] of Resident #2's change of condition or that she was asking to go to the hospital. He said the facility protocol is to send residents to the ER for a change of condition or at the request of the resident. He said the facility should first notify the DON, then the primary physician (or the on- call physician). If a physician cannot be reached the facility knows to call him as, medical director. Review of the facility policy, Significant Change dated ,[DATE], revealed the following: "1. The nursing staff, as well as the interdisciplinary team, will evaluate the patient's/resident's change in status ... 2. The physician, legal representative or appropriate family member will be notified of the change in the patient/resident status when there is: A. An accident resulting in injury and the potential for medical intervention. B. A change in the patient's/resident's physical, mental or psychosocial status ... 3. All significant changes in a patient's/resident's condition will be relayed to the patient's/resident's physician immediately: * If the physician's office is closed, their service will be called; * If contact cannot be made, the Medical Director and Facility Administrator will be notified. * Attempts to reach the physician will continue until the physician is contacted. * All attempts to reach the physician should be thoroughly documented in the medical record." The IJ was called and facility administration was notified on [DATE] at 4:30 p.m. Facility's Plan to Remove Immediate Jeopardy: a) The Interim DON and ADONs will re-educate the licensed nurses regarding performing accurate assessments, documentation of assessments, notification of physician in change of condition, neurological checks and reporting changes in neurological condition during monitoring to the physician. This re-education will begin with the current shift (6:00 p.m. - 6:00 a.m. shift) on [DATE] and oncoming nurses at 5:00 a.m. will be re-educated prior to taking their assignments for their shift. This re-education process will continue throughout the weekend shifts to ensure that licensed nurses caring for the residents have been re-educated as above. A post test will validate staff understanding. The completion date for the re-education will be 6:00 a.m. on [DATE]. b) The Interim DON and ADONs will review the charts of residents with change of conditions to validate that the assessment has been performed, documented, notification of physician occurred, and neurological monitoring (if necessary) have been performed. This chart review will occur each day as part of the nursing leadership meeting Monday through Friday. The nurse managers on duty will check the 24 hour report for any new change of conditions and make observations of the resident to validate that the interventions have been appropriate and documentation reflects care delivered and condition of resident. **Refer to F-9999 for continuation of this deficiency.

Based on interviews and record reviews the facility failed to provide the necessary care and services to maintain the highest practicable physical and mental well-being for 2 of 4 reviewed residents (#1and #2). The facility failed to: a) thoroughly assess Resident #1 and consult with her physian (or physician on-call), after the resident fell and sustained a head injury on [DATE]. The resident died on [DATE]. b) assess and consult with Resident #2's physician when she developed nausea, vomiting, diarrhea, complained of abdominal pain, and was requesting to go to the hospital. Resident #2 suffered a cardiac/respiratory arrest at the facility and was pronounced dead in the ER later that same morning. These failures resulted in an Immediate Jeopardy (IJ). The IJ was called on [DATE]. The immediacy was removed prior to exit on [DATE]. The noncompliance continued at a level of pattern with actual harm that is not immediate jeopardy. Any of the 80 residents in the facility could be affected by these deficient practices. Failure to assess residents' and consult with a physician regarding an injury or a change of condition could result in negative resident outcomes, including death, due to not receiving appropriate medical interventions. Finding included: 1. Record review of Resident #1's Admission Record revealed Resident #1 was an [AGE] year old female, original admitted [DATE] with [DIAGNOSES REDACTED]. Record review of an incident report initiated and signed by LVN E dated [DATE] at 8:15 a.m. revealed that Resident #1 was in the bathroom; she lost her balance and fell , hitting the left side of her head on floor causing a five cm hematoma as well as two skin tears to her left hand. Skin tears measure 1.7 cm X 0.2 cm and 1.1 cm X 0.3cm. Resident #1 had full range of motion to all extremities; no other bruises or redness noted. Resident #1 complained of pain in head and neurological checks were initiated. LVN E wrote on the incident/accident report that she had notified Resident #1's PCP at 9:30 a.m. on [DATE]. Record review of incident investigation (undated) by Administrator and ADON 1 revealed the following: The investigation shows that Housekeeper 1 witnessed Resident #1 fall on the morning of [DATE]. CNA E was making a bed. Housekeeper 1 was in the room, heard a 'thud', saw Resident #1 falling from the adjoining bathroom into room [ROOM NUMBER], hit her head on the dresser and continued to fall to the floor. Both CNA E and Housekeeper 1 tried to get to Resident #1, but were unable to because Resident #1's walker was in the bathroom in front of the sink. CNA E moved it (the walker) out of the way to try to assist her, and then went to the door to call for help as Housekeeper 1 left the room to get help. All staff reported Resident #1 was trying to get up from the floor while they were assessing and monitoring her. Further review of the facility investigation revealed CNA F, LVN E, and CMA 1, entered the room. ADON 2, entered and noticed a skin tear on the resident's hand. Resident #1's right leg was "out of alignment" and ADON 2 evaluated and determined Resident #1 was able to move extremities within her normal abilities. A hematoma was noted on the left side toward the back of her head. Vital signs were taken while Resident #1 was still on the floor. There was no evidence of documentation in Resident #1's clinical record of the vital signs taken while the resident was on the floor. Further review of the facility investigation revealed Resident #1 was assisted up from the floor with a gait belt by CMA 1, LVN E and CNA F. Resident #1 ambulated to her room with assistance of staff and sat in her recliner. LVN E initiated neurological checks. Resident #1 was trying to get up from the recliner without assistance. Between (sic) LVN E and CMA 1 they remained in her room. LVN E continued neurological checks. Resident #1 was reportedly up most of night (Friday night) and slept most of day on Saturday. Sunday Resident #1 was back to ambulating between the lobby and her room. Review of Resident#1's clinical record revealed no evidence of documentation that the resident's PCP was notified of her change of condition. In an interview with ADON 2, on [DATE] at 3:25 p.m. he stated that on [DATE] between 8:00 a.m. and 8:30 a.m. he heard CNA E holler that someone was on the floor. He saw that the Resident #1 was on the floor with the top half of her body in room [ROOM NUMBER] and the lower half of her body in the adjoining restroom; the resident was trying to get up off of the floor. ADON 2 left to answer another resident's call light, came back to assist with Resident #1, and the other people in the room (CMA 1, LVN E, CNA F) were obtaining vital signs. ADON 2 said Resident #1 had a bump on back of her head; he heard the nurse say "hematoma". ADON 2 demonstrated to surveyors that the bump was about middle of the back of her head, "a small bump", about nickel sized, egg shaped, with no blood noted. ADON 2 noted skin tears to Resident #1's left hand, and was concerned that her right leg was "going outward". He was concerned about a possible [MEDICAL CONDITION]. After ascertaining Resident #1 was able to move the right leg, ADON 2 stated that he went back to his office. He said he did not get report on her vital signs and did not notify the resident's PCP. He said he did not feel that Resident #1 needed to be sent to the emergency room to be evaluated at that time. Review of the resident's clinical record revealed no evidence of documentation that ADON 2 notified Resident #1's PCP In an interview with LVN E on [DATE] at 3:55 p.m. concerning Resident #1 falling on [DATE]; LVN E stated that she heard "a loud noise" and went into room [ROOM NUMBER] to find Resident #1 sitting on the floor in the doorway to the bathroom. She said she did a full head to toe assessment, that Resident #1 had full range of motion, noted a "knot" on the left side of her head and two skin tears to the left hand. LVN E stated that she gathered up all of her charting and took it to Resident #1's room to stay with her in order to "keep an eye on her", initiated neurological checks and an incident/accident report. LVN E stated that she spent most of the day in Resident #1's room. She and CNA E were talking about having pizza for lunch, Resident #1 overheard and wanted pizza also, and so LVN E and CNA E shared their pizza with Resident #1. LVN E stated that Resident #1 complained of a headache, so she gave her some Tylenol. LVN E stated that she received a call from the resident's PCP office nurse concerning another resident and LVN E told the office nurse about Resident #1's fall. LVN E was not clear in this interview about what details she reported to the office nurse concerning Resident #1's fall or her condition following the fall. LVN E went on to state that she did notice that Resident #1's blood pressure was low in the beginning, but she does not remember if she reported it or not. LVN E stated she did not feel that Resident #1 needed to go to the emergency room to be evaluated at that time. Record review of physician order sheets dated [DATE] initiated by LVN C, revealed an order to clean Resident #1's skin tears with normal saline, apply TAO, and cover with a light dressing daily and as needed until healed. There was no evidence of any documentation of physician orders related to the 5 cm hematoma to the left side of Resident #1's head. Review of the neurological assessment sheet revealed blood pressure and pulse rates taken and recorded after Resident #1 was moved from the floor to her recliner: [DATE]: 8:15 a.m. BP ,[DATE] (low), P 116 (high) 8:30 a.m. BP ,[DATE] (low), P 70; 8:45 a.m. BP ,[DATE], P 86; 10:00 a.m. ,[DATE] (high), P 68; 10:30 a.m. BP ,[DATE] (high), P 68; 12:00 noon BP ,[DATE] (high), P 76. [DATE]: 3:00 p.m. BP ,[DATE], P 74; [DATE]: (no time) BP ,[DATE], P 84. There was no evidence of documentation that any of these readings were communicated to Resident #1's PCP. Record review of Nurses' Notes dated [DATE] at 8:15 a.m. by LVN E revealed: "heard loud noise and found this resident on floor in doorway of bathroom, lost balance and fell - hit left side of head on floor causing five cm hematoma and two skin tears on left hand (1.7 cm X 0.2cm) and (1.1 cm X 0.3 cm), area cleansed with normal saline, triple antibiotic ointment and light dressing applied - Neurological checks initiated - full range of motion to all extremities; no other bruises or redness noted at this time, (ADON 1), PCP and family notified - sitting in recliner and up to bathroom several times with walker and assistance." There was no evidence of notation about the initial low BP and elevated pulse rate being communicated to the PCP. Record review of Nurse's Notes dated [DATE] at 6:00 p.m. by LVN D revealed: "sitting in recliner. Resting; Complained of headache, took as needed dose of Tylenol 500 milligrams po given." Record review of a second Incident/Accident Investigation Worksheet dated [DATE] at 7:00 p.m. by LVN D revealed: "Resident fell in front lobby; witness by two aides..."paged MD on call - no response" (no time). Resident #1 was sent to a local hospital emergency room (ER) at 7:35 p.m. Record review of Nurses Notes dated [DATE] revealed that Resident #1's second fall occurred on [DATE] in the evening around 7 p.m. Resident #1 continued the same routine, ambulating to the lobby and back to the bathroom. Resident #1 was sitting in the green chair in the lobby, attempting to get up, and requested help. CNA C assisted her up and the resident ambulated toward the back of the couch, went to turn back toward the green chair after she complained of shortness of breath. CNA C was at Resident's # 1's side and called for CNA D's assistance as CNA C was attempting to get the resident seated. Resident #1 yelled, "I'm falling", then let go of her walker and fell backwards hitting her upper back on the shoulder of the couch. LVN D assessed Resident #1, noted an old purple bruise to left side of head (from the fall on Friday [DATE]). No other new bruises, hematomas or new skin tears were noted. Resident #1 complained of a headache and hurting all over. In an interview with CNA D on [DATE] at 10:35 a.m. he said for a couple of days before the second fall (on [DATE]) Resident #1 had been more confused than usual. He said she kept repeatedly asking for help to go to the bathroom. In an interview with CNA H on [DATE] at 2:53 p.m. she said she worked the two days after Resident #1's first fall ([DATE]). She said the resident was not eating (feeding herself) and had to be fed by staff at least one meal on Saturday ([DATE]). She said she noticed when the resident was in her recliner she was leaning 45 to 90 degrees to the left. In an interview with CNA G on [DATE] at 3:55 p.m. she said she has worked at this facility since ,[DATE] and has been a CNA since 1995. CNA G stated she was not working during either of Resident #2's falls, but did work Saturday [DATE], the day after the first fall, and Sunday [DATE]. CNA G went on to state that on that Saturday, Resident #1 stayed in her room, and slept most of day, which was very unusual for Resident #1, and Resident #1 stated "I don't feel good." CNA G stated that on Sunday [DATE] during the day Resident #1 was up and about in her usual manner, but was more confused than usual. Record review of the ER notes from local hospital dated [DATE] revealed that Resident #1 was agitated, repeatedly requested "help me, somebody please help me." Resident #1 complained of headache, blood pressure and heart rate elevated (initial BP ,[DATE], P 111 at 7:48 p.m.); at 8:20 p.m. Resident #1's BP was ,[DATE], no pulse rate recorded); pupils were sluggish and the resident needed to be restrained due to continued agitation. Record review of the Radiology and Nuclear Medicine reports from local hospital dated [DATE] at 7:59 p.m. revealed, "An acute 1.3 cm right sided subdural hematoma is seen with midline shift from right to left approximately 0.7 cm. Left parietal scalp swelling/hematoma is present. No underlying fractures identified. Mild cortical and cerebellar atrophy is present. Impression: "1. Acute right sided subdural hematoma with midline shift; 2. Left parietal soft tissue swelling." According to <http://www.medlineplus.com>: "An acute subdural hematoma (SDH) is a rapidly clotting blood collection below the inner layer of the dura but external to the brain and arachnoids' membrane. A subdural hematoma (SDH) is the most common type of intracranial mass lesion, occurring in about a third of those with severe head injuries. Subdural hematoma is more common in people older than [AGE] years. The elderly are predisposed to cerebral atrophy because they have less resilient bridging veins. Moreover, these veins can be damaged more easily in the elderly. Suspect acute subdural hematoma whenever the patient has experienced a mechanism of moderately severe to severe [MEDICATION NAME] head trauma." Record review of Physician's Progress notes from local hospital dated [DATE] at 9:50 p.m. by neurological admitting physician revealed, "Diagnosis: [REDACTED]." Record review from the Department of Radiology and Nuclear Medicine from local hospital dated [DATE] at 8:00 a.m. revealed: "Impression: Significant enlargement of the patient's (Resident #1) right subdural hematoma..." Record review of the Progress Notes from local hospital dated [DATE] revealed: "Death Note...Time of death was at 1343 (1:43 p.m.)." In a telephone interview with Resident #1's physician office nurse on [DATE] at 10:42 a.m., she stated that the PCP was out of town from [DATE] to [DATE]. She said she checked all of the telephone logs for the PCP and the covering physician from that time period, particularly [DATE] when LVN E stated that she had notified the PCP's office. There was no evidence of any calls to or from the facility on [DATE]. In an interview with the facility's Medical Director on [DATE] at 1:00 p.m., he stated he was not notified of Resident #1's change of condition. He stated that the protocol was to send any resident to the emergency room at any time the resident requests, or at any time there is a change of condition. The Medical Director stated that the staff must notify the DON first, then the attending physician or the covering physician and if either physician were not available to call him (the facility Medical Director). During an interview with ADON 1 on [DATE] at 1:50 p.m. she said she was off on [DATE] when Resident #1 fell . She said the facility did not have a DON at that time and she (ADON 1) was not notified of the incident. She said, in hindsight, Resident #1 should have been sent to the ER for evaluation after falling and hitting her head. In a telephone interview with the Neurologist for Resident #1 on [DATE] at 5:05 p.m., he stated that when the resident was admitted to the hospital he was not aware that she had fallen and struck her head on [DATE]. He stated that through his record review and the condition of Resident #1's subdural hematoma, that the subdural hematoma likely occurred during the first fall on [DATE], especially since she did not strike her head during the second fall on [DATE]. The neurologist went on to state, "Any time any resident falls, whether it was a witnessed fall or an unwitnessed fall, if there is any suspicion the resident might have hit their head on anything, the resident needs to be evaluated immediately at the ER." 2. Record review of Resident #2's Admission Record revealed she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Her CPR status was Full Code. Record review of the MDS assessment dated [DATE] revealed her speech was clear, she was able to comprehend others, was able to express herself and make herself understood. She required extensive assistance of two people for bed mobility. She was not able to ambulate and was confined to the bed or wheelchair. She required extensive assistance for dressing toileting and bathing. She had an indwelling urinary catheter and a [MEDICAL CONDITION]. She was 4' 8" tall and weighed 68 lbs. Record review of the facility's investigation report by ADON 1 dated [DATE] revealed the following: 1) At approximately 1:30 p.m. CNA A and CNA B came to her office and reported that the charge nurse (LVN A) was aware that Resident #2 wanted to go to the hospital, she had been sick all day, and just wasn't acting right. After being notified of this, ADON 1 documented that she and the Administrator called LVN A into the office to speak with her. The interview revealed that she was aware of Resident #2 vomiting, her complaints of stomach pain, and not feeling well. LVN A was also aware of the resident's requests to go to the hospital, but could not explain why she did not send the resident to the hospital. 2) LVN A documented that a fax was sent (no time noted) to Resident #2's physician concerning her vomiting and requesting some other medication besides [MEDICATION NAME] for this. This physician requests all faxes to be placed in his box at the facility and he addresses them when he comes in to make rounds, which is usually after lunch, and LVN A was aware of this. LVN A did not call the Resident's physician regarding her change of condition. 3) LVN A documented in the nurses' notes that Resident #2 had vomited in the dining room, but investigation revealed the resident did not get out of bed that morning. Breakfast had been brought to her room but she refused everything except cream of wheat. CNA A was monitoring the hall while CNA B was feeding residents' breakfast in the dining room. At approximately 8:15 a.m. LVN A went to the dining room to get CNA B to go assist CNA A to clean up Resident #2 after she had an episode of vomiting. Both CNA A and CNA B reported to LVN A that the resident had complained of not feeling well, complained of stomach pain, did not look well and had slurred speech. 4) LVN B (medication nurse) went to Resident #2's room (no time noted) to give her a pain pill ([MEDICATION NAME]) which she refused at that time because of nausea and vomiting. LVN B gave the resident [MEDICATION NAME]. 5) At approximately 9:00 a.m. CNA A, CNA B, and LVN C (treatment nurse) were in Resident #2's room, changing her [MEDICAL CONDITION] bag after an episode of diarrhea. LVN A came into the room and CNA B was talking to the resident, and the resident was saying she wanted to go to the hospital. LVN C said she did not hear her say that but did say the resident "did not look right". LVN C said she asked the resident what was wrong and the resident said she didn't know but something was not right, but could not explain what. LVN C left the room and thought that LVN A would call the doctor. LVN C said she was not aware Resident #2's physician was not notified until after the resident had coded. 6) LVN A said Resident #2 (no time noted) turned on her call light. When she went to the resident's room she was short of breath, her O2 sats were in the 90's (normal) so she elevated the head of the bed. The oxygen was continuous and was in place. LVN A said the resident acted like she wanted to get out of bed. As LVN A was leaving the room she saw CNA B as she was taking a resident to the dining room for lunch and told her go ahead and get Resident #2 up for lunch, it might help her stomach. 7) CNA B went to Resident #2's room then left to get a washcloth (no time noted). She told LVN A that the Resident did not look good. CNA B returned to the resident's room and found her with her eyes wide open and her left arm shaking. CNA B summoned LVN A. LVN A was unable to get a blood pressure on the resident. ADON 1 was summoned. She found the resident unresponsive, pupils fixed and dilated, with no pulse or blood pressure. CPR was initiated and 911 was called. Fluids kept coming from the resident's mouth requiring her to be suctioned intermittently. The fire department arrived and took over CPR. The ambulance arrived and the resident was taken to the ER. Record review of the Provider Investigation Report dated [DATE] revealed Resident #2 had a history of [REDACTED]. The incident occurred on [DATE]. Under Description of the Allegation it was documented that the resident had nausea and vomiting and requested to go to the hospital. Resident was given [MEDICATION NAME] (a medication for indigestion) and [MEDICATION NAME] (a pain medication). Resident was found unresponsive at 10:50 a.m. Under Description of Injury it was documented that the resident was found unresponsive with no pulse or blood pressure. Her pupils were fixed and dilated. Under Description of Assessment it was documented that vital signs were assessed and CPR initiated. Under Provider Response it was documented that the initial assessment was incomplete because resident request was not honored and physician not notified of change in condition. Record review of the nurses' notes revealed the following entry on [DATE] by LVN A: (No time entered) "Resident up in w/c to D/R for breakfast. Started c/o stomach hurting. [MEDICATION NAME] 30cc P.O. given for discomfort. Vomited small amt. emesis - Resident put back to bed. Positioned on left side - [MEDICAL CONDITION] bag changed, had loose stool." "0930 (9:30 a.m.) C/o stomach still hurting. [MEDICATION NAME] 1 p.o. given (50 mg)." (No time entered) "ADLs done by staff - Foley catheter patent ..." (No time entered) "Fax to Dr.___ about vomiting ask for something else besides [MEDICATION NAME]." Review of a fax to Dr. ___ dated [DATE] (no time) revealed the following: " *comments: (Resident #2) Resident vomited x1 at breakfast table - brought back to room [MEDICATION NAME] was given still complained of pain [MEDICATION NAME] 50 mg 1 p.o. given - Resident had loose stool - [MEDICAL CONDITION] bag was changed. Resident confused at times - Could we have something else for nausea besides [MEDICATION NAME]" Further review of nurses' notes dated [DATE] by LVN A revealed the following: "1050 (10:50 a.m.) Resident sleeping appears to be resting comfortably...resident turned on call light when nurse went to room resident was talking - stated she was SOB. - O2 sat. 98% HOB (elevated) when nurse asked if she wanted to sit up in w/c she acted as if she was going to get out of bed - Ask CNA to help her get up - when CNA entered room resident was not responding - pupils were dilated - Crash cart was brought to room and 911 called. CPR initiated by (ADON 1) and (ADON 2) - Resident vomited large amount brown liquid. Resident suctioned obtained small amt brown liquid - 02 via nasal cannula at 3 LPM - Resident still unresponsive. " "1115 (11:15 a.m.) ___ Ambulance here CPR administered by ___ Ambulance - unable to obtain heart beat. Resident transferred to (hospital)." Review of the hospital emergency room records revealed Resident #2 arrived in theER on [DATE] at 11:35 a.m. with CPR still in progress. The ER physician and staff were unable to revive Resident #2 and she died . Her death was pronounced at 11:46 a.m. During an interview with LVN B on [DATE] at 11:25 a.m. she said she was told on [DATE], around breakfast time, by LVN A that Resident #2 needed something for pain. She said she took the resident an [MEDICATION NAME] but the resident said she couldn't take it because she was nauseated. LVN B said she gave her [MEDICATION NAME] instead at that time and returned later and gave her the [MEDICATION NAME]. LVN B said she started working at the facility a couple of months ago on a prn basis. She said they call her to work if someone calls in. She said she thought [DATE] was only her second time to work in the facility and said she "really didn't know these residents." LVN B did not assess the resident and did not notify the resident ' s physician of her change of condition. During an interview with CNA A on [DATE] at 11:35 a.m. she said Resident #2 didn't want to get up for breakfast that morning ([DATE]). She said she took her breakfast tray to her room but she didn't want anything. She said she was passing the other hall trays when the med nurse (LVN B) told her that Resident #2 had vomited. She said she got CNA B to help her clean up the resident. She said Resident #2 was asking to see the doctor or to go to the hospital. She said as the morning went on she "just wasn't herself." She complained of aching and having mid-abdominal pain. She said "she was not as talkative as usual and was more withdrawn, and she just kept saying she hurt and needed to see the doctor." She said LVN A was aware that Resident #2 was asking to go to the hospital. During an interview on [DATE] at 2:10 p.m. ADON 1 said she was in charge at the facility on [DATE]. She said she was unaware of Resident #2's change of condition or her requests to be sent to the hospital that morning. She said when she responded to the code, Resident #2 was not breathing and had no blood pressure or pulse. She said she initiated CPR and had 911 called. She said they had to interrupt CPR several times to suction dark brown fluid from the resident's mouth. ADON 1 said that her investigation revealed that no one (LVN A, B or C) had notified Resident #2's physician of her change of condition or her requests to be sent to the hospital. She said LVN A had just put a fax in the doctor's box asking for something besides [MEDICATION NAME] for her nausea and vomiting. During an interview with LVN A on [DATE] at 4:30 p.m. she said that on [DATE] around 8:30 a.m. she was told by CNA B that Resident #2 had vomited. She said she asked LVN B (medication nurse) if she had given the resident anything for nausea and that LVN B said she had given her [MEDICATION NAME]. LVN A said she went to the resident's room to check on her and the resident said her stomach was hurting. She had diarrhea in her [MEDICAL CONDITION] bag. LVN A said the resident settled down for a little while but was woke up by hammering in a nearby room that was being renovated. She put on her call light and said she was not feeling good. LVN A said she had faxed the doctor and he would see her when he made rounds. She said Resident #2 did ask to go the hospital but she had only vomited once. She said Resident #2 had so many things wrong with her it was sometimes hard to know what was going on with her. When asked if she assessed the resident that morning she said, "I looked at her, but I don't really remember." When asked if she took the resident's vital signs she said, "I think so. If I did it would be in the nurses' notes." Review of nurses' notes for Resident #2 dated [DATE] revealed the only entries made were by LVN A. No assessment and no vital signs had been documented. During an interview on [DATE] at 1:00 p.m. with Resident #2's physician (facility's Medical Director) he said he was not notified on [DATE] of Resident #2's change of condition or that she was asking to go to the hospital. He said the facility protocol is to send residents to the ER for a change of condition or at the request of the resident. He said the facility should first notify the DON, then the primary physician (or the on- call physician). If a physician cannot be reached the facility knows to call him as, medical director. Review of the facility policy, Significant Change dated ,[DATE], revealed the following: "1. The nursing staff, as well as the interdisciplinary team, will evaluate the patient's/resident's change in status ... 2. The physician, legal representative or appropriate family member will be notified of the change in the patient/resident status when there is: A. An accident resulting in injury and the potential for medical intervention. B. A change in the patient's/resident's physical, mental or psychosocial status ... 3. All significant changes in a patient's/resident's condition will be relayed to the patient's/resident's physician immediately: * If the physician's office is closed, their service will be called; * If contact cannot be made, the Medical Director and Facility Administrator will be notified. * Attempts to reach the physician will continue until the physician is contacted. * All attempts to reach the physician should be thoroughly documented in the medical record." The IJ was called and facility administration was notified on [DATE] at 4:30 p.m. Facility's Plan to Remove Immediate Jeopardy: a) The Interim DON and ADONs will re-educate the licensed nurses regarding performing accurate assessments, documentation of assessments, notification of physician in change of condition, neurological checks and reporting changes in neurological condition during monitoring to the physician. This re-education will begin with the current shift (6:00 p.m. - 6:00 a.m. shift) on [DATE] and oncoming nurses at 5:00 a.m. will be re-educated prior to taking their assignments for their shift. This re-education process will continue throughout the weekend shifts to ensure that licensed nurses caring for the residents have been re-educated as above. A post test will validate staff understanding. The completion date for the re-education will be 6:00 a.m. on [DATE]. b) The Interim DON and ADONs will review the charts of residents with change of conditions to validate that the assessment has been performed, documented, notification of physician occurred, and neurological monitoring (if necessary) have been performed. This chart review will occur each day as part of the nursing leadership meeting Monday through Friday. The nurse managers on duty will check the 24 hour report for any new change of conditions and make observations of the resident to validate that the interventions have been appropriate and documentation reflects care delivered and condition of resident. c) The Interim DON or designee will review incidents and investigations for appropriate follow-up and interventions Monday through Friday as part of nursing leadership meeting. d) The Performance Improvement Committee will review the results of audits for trends, patterns and concerns monthly. On [DATE] the surveyors confirmed through interviews and record reviews: a) Nursing staff had been re-educated on performing accurate assessments, documentation of assessments, notification of physician in change of condition, neurological checks and reporting changes in neurological condition during monitoring to the physician. Nursing staff in-services were conducted on [DATE] at 5:00 a.m. and 5:00 p.m. and on [DATE] at 5:00 p.m.; b) Charts of residents with change of conditions were being reviewed to validate that assessments had been performed, documented, notification of physician occurred, and neurological monitoring (if necessary) had been performed. Observations of the residents were made by nurse managers to validate that the interventions were appropriate and documentation reflected care delivered and condition of resident; c) Incidents and investigations were being reviewed by nurse managers for appropriate follow-up and interventions. The immediacy was removed on [DATE] at 3:30 p.m. The facility remained out of compliance at the level of pattern with actual harm that is not immediate jeopardy because they had not yet monitored or evaluated the action plan for effectiveness. Review of the CMS 672, Resident Census and Conditions of Residents, dated [DATE] revealed a facility census of 80 residents.

Based on interviews and record reviews the facility administrator failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently for 2 of 4 residents (#1 and #2) reviewed with changes of condition. The facility administrator failed to: a) supervise nursing staff in the absence of a DON to ensure residents were assessed and physicians were notified for residents with changes of condition (Resident #1 and #2). b) ensure implementation of facility policy and procedures regarding significant change of condition for Resident #1 and Resident #2. These failures resulted in an Immediate Jeopardy (IJ). An IJ was called on [DATE]. The immediacy was removed prior to exit on [DATE]. The noncompliance continued at a level of pattern with actual harm that is not immediate jeopardy. Any of the 80 residents in the facility could be affected by these deficient practices. Failure to assess residents' and consult with a physician regarding an injury or a change of condition could result in negative resident outcomes, including death, due to not receiving appropriate medical interventions. Finding included: 1. In an interview on [DATE] at 2:45 p.m. with facility Corporate VP revealed the facility had been without effective leadership during the past two years. The facility staff had not been following facility policies and procedures due to the lack of effective management during this time. She went on to reveal that the current administrator did not think that the incidents involving Resident #1 and Resident #2 were reportable to DADS. The Corporate VP stated she had to force the administrator to report these incidents to DADS resulting in Administrator turning in his resignation effective [DATE]. 2. In an interview on [DATE] at 5:30 p.m. the facility Corporate VP revealed that today would be the administrator's last day of employment with the facility. She stated, "We need to get some effective leadership in this building." 3. In an interview on [DATE] at 11:13 a.m. with ADON 1 described the high level of stress and frustration she has felt from not having adaquate administrative support for approximately the past two years. ADON 1 revealed the facility has had four different DONs during this time. She said she has been "struggling to try to hold everything together." ADON 1 revealed that a lot of her stress and frustration has been relieved since Corporate Interim DON arrived last week. 4. Record review of Resident #1's Admission Record revealed Resident #1 was an [AGE] year old female, original admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 was ambulatory with wheeled walker, was able to make her needs known and was able to feed herself independently. Record review of an incident report initiated and signed by LVN E dated [DATE] at 8:15 a.m. revealed that Resident #1 was in the bathroom; she lost her balance and fell , hitting the left side of her head on floor causing a five cm hematoma as well as two skin tears to her left hand. Skin tears measure 1.7 cm X 0.2 cm and 1.1 cm X 0.3cm. Resident #1 had full range of motion to all extremities; no other bruises or redness noted. Resident #1 complained of pain in head and neurological checks were initiated. LVN E wrote on the incident/accident report that she had notified Resident #1's PCP at 9:30 a.m. on [DATE]. Record review of incident investigation (undated) by Administrator and ADON 1 revealed the following: The investigation shows that Housekeeper 1 witnessed Resident #1 fall on the morning of [DATE]. CNA E was making a bed. Housekeeper 1 was in the room, heard a 'thud', saw Resident #1 falling from the adjoining bathroom into room [ROOM NUMBER], hit her head on the dresser and continued to fall to the floor. Both CNA E and Housekeeper 1 tried to get to Resident #1, but were unable to because Resident #1's walker was in the bathroom in front of the sink. CNA E moved it (the walker) out of the way to try to assist her, and then went to the door to call for help as Housekeeper 1 left the room to get help. All staff reported Resident #1 was trying to get up from the floor while they were assessing and monitoring her. Further review of the facility investigation revealed CNA F, LVN E, and CMA 1, entered the room. ADON 2, entered and noticed a skin tear on the resident's hand. Resident #1's right leg was "out of alignment" and ADON 2 evaluated and determined Resident #1 was able to move extremities within her normal abilities. A hematoma was noted on the left side toward the back of her head. Vital signs were taken while Resident #1 was still on the floor. There was no evidence of documentation in Resident #1's clinical record of the vital signs taken while the resident was on the floor. Further review of the facility investigation revealed Resident #1 was assisted up from the floor with a gait belt by CMA 1, LVN E and CNA F. Resident #1 ambulated to her room with assistance of staff and sat in her recliner. LVN E initiated neurological checks. Resident #1 was trying to get up from the recliner without assistance. Between (sic) LVN E and CMA 1 they remained in her room. LVN E continued neurological checks. Resident #1 was reportedly up most of night (Friday night) and slept most of day on Saturday. Sunday Resident #1 was back to ambulating between the lobby and her room. Review of Resident#1's clinical record revealed no evidence of documentation that the resident's PCP was notified of her change of condition. In an interview with ADON 2, on [DATE] at 3:25 p.m. he stated that on [DATE] between 8:00 a.m. and 8:30 a.m. he heard CNA E holler that someone was on the floor. He saw that the Resident #1 was on the floor with the top half of her body in room [ROOM NUMBER] and the lower half of her body in the adjoining restroom; the resident was trying to get up off of the floor. ADON 2 left to answer another resident's call light, came back to assist with Resident #1, and the other people in the room (CMA 1, LVN E, CNA F) were obtaining vital signs. ADON 2 said Resident #1 had a bump on back of her head; he heard the nurse say "hematoma". ADON 2 demonstrated to surveyors that the bump was about middle of the back of her head, "a small bump", about nickel sized, egg shaped, with no blood noted. ADON 2 noted skin tears to Resident #1's left hand, and was concerned that her right leg was "going outward". He was concerned about a possible [MEDICAL CONDITION]. After ascertaining Resident #1 was able to move the right leg, ADON 2 stated that he went back to his office. He said he did not get report on her vital signs and did not notify the resident's PCP. He said he did not feel that Resident #1 needed to be sent to the emergency room to be evaluated at that time. Review of the resident's clinical record revealed no evidence of documentation that ADON 2 notified Resident #1's PCP. In an interview with LVN E on [DATE] at 3:55 p.m. concerning Resident #1 falling on [DATE]; LVN E stated that she heard "a loud noise" and went into room [ROOM NUMBER] to find Resident #1 sitting on the floor in the doorway to the bathroom. She said she did a full head to toe assessment, that Resident #1 had full range of motion, noted a "knot" on the left side of her head and two skin tears to the left hand. LVN E stated that she gathered up all of her charting and took it to Resident #1's room to stay with her in order to "keep an eye on her", initiated neurological checks and an incident/accident report. LVN E stated that she spent most of the day in Resident #1's room. She and CNA E were talking about having pizza for lunch, Resident #1 overheard and wanted pizza also, and so LVN E and CNA E shared their pizza with Resident #1. LVN E stated that Resident #1 complained of a headache, so she gave her some Tylenol. LVN E stated that she received a call from the resident's PCP office nurse concerning another resident and LVN E told the office nurse about Resident #1's fall. LVN E was not clear in this interview about what details she reported to the office nurse concerning Resident #1's fall or her condition following the fall. LVN E went on to state that she did note that Resident #1's blood pressure was low in the beginning, but she does not remember if she reported it or not. LVN E stated she did not feel that Resident #1 needed to go to the emergency room to be evaluated at that time. Record review of physician order sheets dated [DATE] initiated by LVN C, revealed an order to clean Resident #1's skin tears with normal saline, apply TAO, and cover with a light dressing daily and as needed until healed. There was no evidence of any documentation of physician orders related to the 5 cm hematoma to the left side of Resident #1's head. Review of the neurological assessment sheet revealed blood pressure and pulse rates taken and recorded after Resident #1 was moved from the floor to her recliner: [DATE]: 8:15 a.m. BP ,[DATE] (low), P 116 (high); 8:30 a.m. BP ,[DATE] (low), P 70; 8:45 a.m. BP ,[DATE], P 86; 10:00 a.m. ,[DATE] (high), P 68; 10:30 a.m. BP ,[DATE] (high), P 68; 12:00 noon BP ,[DATE] (high), P 76. [DATE]: 3:00 p.m. BP ,[DATE], P 74; [DATE]: (no time) BP ,[DATE], P 84. There was no evidence of documentation that any of these readings were communicated to Resident #1's PCP. Record review of Nurses' Notes dated [DATE] at 8:15 a.m. by LVN E revealed: "heard loud noise and found this resident on floor in doorway of bathroom, lost balance and fell - hit left side of head on floor causing five cm hematoma and two skin tears on left hand (1.7 cm X 0.2cm) and (1.1 cm X 0.3 cm), area cleansed with normal saline, triple antibiotic ointment and light dressing applied - Neurological checks initiated - full range of motion to all extremities; no other bruises or redness noted at this time, (ADON 1), PCP and family notified - sitting in recliner and up to bathroom several times with walker and assistance." There was no evidence of notation about the initial low BP and elevated pulse rate being communicated to the PCP. Record review of Nurse's Notes dated [DATE] at 6:00 p.m. by LVN D revealed: "sitting in recliner. Resting; Complained of headache, took as needed dose of Tylenol 500 milligrams po given." Record review of a second Incident/Accident Investigation Worksheet dated [DATE] at 7:00 p.m. by LVN D revealed: "Resident fell in front lobby; witness by two aides..."paged MD on call - no response" (no time). Resident #1 was sent to a local hospital emergency room (ER) at 7:35 p.m. Record review of Nurses Notes dated [DATE] revealed that Resident #1's second fall occurred on [DATE] in the evening around 7 p.m. Resident #1 continued the same routine, ambulating to the lobby and back to the bathroom. Resident #1 was sitting in the green chair in the lobby, attempting to get up, and requested help. CNA C assisted her up and the resident ambulated toward the back of the couch, went to turn back toward the green chair after she complained of shortness of breath. CNA C was at Resident's # 1's side and called for CNA D's assistance as CNA C was attempting to get the resident seated. Resident #1 yelled, "I'm falling", then let go of her walker and fell backwards hitting her upper back on the shoulder of the couch. LVN D assessed Resident #1, noted an old purple bruise to left side of head (from the fall on Friday [DATE]). No other new bruises, hematomas or new skin tears were noted. Resident #1 complained of a headache and hurting all over. In an interview with CNA D on [DATE] at 10:35 a.m. he said for a couple of days before the second fall (on [DATE]) Resident #1 had been more confused than usual. He said she kept repeatedly asking for help to go to the bathroom. In an interview with CNA H on [DATE] at 2:53 p.m. she said she worked the two days after Resident #1's first fall ([DATE]). She said the resident was not eating (feeding herself) and had to be fed by staff at least one meal on Saturday ([DATE]). She said she noticed when the resident was in her recliner she was leaning 45 to 90 degrees to the left. In an interview with CNA G on [DATE] at 3:55 p.m. she said she has worked at this facility since ,[DATE] and has been a CNA since 1995. CNA G stated she was not working during either of Resident #2's falls, but did work Saturday [DATE], the day after the first fall, and Sunday [DATE]. CNA G went on to state that on that Saturday, Resident #1 stayed in her room, and slept most of day, which was very unusual for Resident #1, and Resident #1 stated "I don't feel good." CNA G stated that on Sunday [DATE] during the day Resident #1 was up and about in her usual manner, but was more confused than usual. Record review of the ER notes from local hospital dated [DATE] revealed that Resident #1 was agitated, repeatedly requested "help me, somebody please help me." Resident #1 complained of headache, blood pressure and heart rate elevated (initial BP ,[DATE], P 111 at 7:48 p.m.); at 8:20 p.m. Resident #1's BP was ,[DATE], no pulse rate recorded); pupils were sluggish and the resident needed to be restrained due to continued agitation. Record review of the Radiology and Nuclear Medicine reports from local hospital dated [DATE] at 7:59 p.m. revealed, "An acute 1.3 cm right sided subdural hematoma is seen with midline shift from right to left approximately 0.7 cm. Left parietal scalp swelling/hematoma is present. No underlying fractures identified. Mild cortical and cerebellar atrophy is present. Impression: "1. Acute right sided subdural hematoma with midline shift; 2. Left parietal soft tissue swelling." A subdural hematoma according to <http://www.medlineplus.com> is defined as: "An acute subdural hematoma (SDH) is a rapidly clotting blood collection below the inner layer of the dura but external to the brain and arachnoids' membrane. A subdural hematoma (SDH) is the most common type of intracranial mass lesion, occurring in about a third of those with severe head injuries. Subdural hematoma is more common in people older than [AGE] years. The elderly are predisposed to cerebral atrophy because they have less resilient bridging veins. Moreover, these veins can be damaged more easily in the elderly. Suspect acute subdural hematoma whenever the patient has experienced a mechanism of moderately severe to severe [MEDICATION NAME] head trauma." Record review of Physician's Progress notes from local hospital dated [DATE] at 9:50 p.m. by neurological admitting physician revealed, "Diagnosis: [REDACTED]." Record review from the Department of Radiology and Nuclear Medicine from local hospital dated [DATE] at 8:00 a.m. reveals: "Impression: Significant enlargement of the patient's (Resident #1) right subdural hematoma, with maximum depth of three cm, and currently two cm of right-to-left midline shift, with significant subfalcine herniation, and effacement of the basilar cisterns, as well as developing [DIAGNOSES REDACTED]." Record review of the Progress Notes from local hospital dated [DATE] at 8:00 a.m. the Neurologist stated "I spoke with the family (Resident #1); they do not wish aggressive surgical treatment - hospice consult." Record review of the Progress Notes from local hospital dated [DATE] at 9:10 a.m. from Physical Therapist (PT) revealed: "Patient (Resident #1) with decline in status, unresponsive this morning." Record review of the Progress Notes from local hospital dated [DATE] revealed: "Death Note - Patient lost vital signs, family requested resuscitations initially; patient was given [MEDICATION NAME] and had a brief return. Then family decided to stop code and patient expired. Time of death was at 1343 (1:43 p.m.)." In a telephone interview with Resident #1's physician office nurse on [DATE] at 10:42 a.m., she stated that the PCP was out of town from [DATE] to [DATE]. She said she checked all of the telephone logs for the PCP and the covering physician from that time period, particularly [DATE] when LVN E stated that she had notified the PCP's office. There was no evidence of any calls to or from the facility on [DATE]. In an interview with the facility's Medical Director on [DATE] at 1:00 p.m., he stated he was not notified of Resident #1's change of condition. He stated that the protocol was to send any resident to the emergency room at any time the resident requests, or at any time there is a change of condition. The Medical Director stated that the staff must notify the DON first, then the attending physician or the covering physician and if either physician were not available to call him (the facility Medical Director). In a telephone interview with the Neurologist for Resident #1 on [DATE] at 5:05 p.m., he stated that when the resident was admitted to the hospital he was not aware that she had fallen and struck her head on [DATE]. He stated that through his record review and the condition of Resident #1's subdural hematoma, that the subdural hematoma likely occurred during the first fall on [DATE], especially since she did not strike her head during the second fall on [DATE]. The neurologist went on to state, "Any time any resident falls, whether it was a witnessed fall or an unwitnessed fall, if there is any suspicion the resident might have hit their head on anything, the resident needs to be evaluated immediately at the ER." 5. Record review of Resident #2's Admission Record revealed she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Her CPR status was Full Code. Record review of the MDS assessment dated [DATE] revealed her speech was clear, she was able to comprehend others, was able to express herself and make herself understood. She required extensive assistance of two people for bed mobility. She was not able to ambulate and was confined to the bed or wheelchair. She required extensive assistance for dressing toileting and bathing. She had an indwelling urinary catheter and a [MEDICAL CONDITION]. She was 4' 8" tall and weighed 68 lbs. Record review of the facility's investigation report by ADON 1 dated [DATE] revealed the following: 1) At approximately 1:30 p.m. CNA A and CNA B came to her office and reported that the charge nurse (LVN A) was aware that Resident #2 wanted to go to the hospital, she had been sick all day, and just wasn't acting right. After being notified of this, ADON 1 documented that she and the Administrator called LVN A into the office to speak with her. The interview revealed that she was aware of Resident #2 vomiting, her complaints of stomach pain, and not feeling well. LVN A was also aware of the resident's requests to go to the hospital, but could not explain why she did not send the resident to the hospital. 2) LVN A documented that a fax was sent (no time noted) to Resident #2's physician concerning her vomiting and requesting some other medication besides [MEDICATION NAME] for this. This physician requests all faxes to be placed in his box at the facility and he addresses them when he comes in to make rounds, which is usually after lunch, and LVN A was aware of this. LVN A did not call the Resident's physician regarding her change of condition. 3) LVN A documented in the nurses' notes that Resident #2 had vomited in the dining room, but investigation revealed the resident did not get out of bed that morning. Breakfast had been brought to her room but she refused everything except cream of wheat. CNA A was monitoring the hall while CNA B was feeding residents' breakfast in the dining room. At approximately 8:15 a.m. LVN A went to the dining room to get CNA B to go assist CNA A to clean up Resident #2 after she had an episode of vomiting. Both CNA A and CNA B reported to LVN A that the resident had complained of not feeling well, complained of stomach pain, did not look well and had slurred speech. 4) LVN B (medication nurse) went to Resident #2's room (no time noted) to give her a pain pill ([MEDICATION NAME]) which she refused at that time because of nausea and vomiting. LVN B gave the resident [MEDICATION NAME]. 5) At approximately 9:00 a.m. CNA A, CNA B, and LVN C (treatment nurse) were in Resident #2's room, changing her [MEDICAL CONDITION] bag after an episode of diarrhea. LVN A came into the room and CNA B was talking to the resident, and the resident was saying she wanted to go to the hospital. LVN C said she did not hear her say that but did say the resident "did not look right". LVN C said she asked the resident what was wrong and the resident said she didn't know but something was not right, but could not explain what. LVN C left the room and thought that LVN A would call the doctor. LVN C said she was not aware Resident #2's physician was not notified until after the resident had coded. 6) LVN A said Resident #2 (no time noted) turned on her call light. When she went to the resident's room she was short of breath, her O2 sats were in the 90's (normal) so she elevated the head of the bed. The oxygen was continuous and was in place. LVN A said the resident acted like she wanted to get out of bed. As LVN A was leaving the room she saw CNA B as she was taking a resident to the dining room for lunch and told her go ahead and get Resident #2 up for lunch, it might help her stomach. 7) CNA B went to Resident #2's room then left to get a washcloth (no time noted). She told LVN A that the Resident did not look good. CNA B returned to the resident's room and found her with her eyes wide open and her left arm shaking. CNA B summoned LVN A. LVN A was unable to get a blood pressure on the resident. ADON 1 was summoned. She found the resident unresponsive, pupils fixed and dilated, with no pulse or blood pressure. CPR was initiated and 911 was called. Fluids kept coming from the resident's mouth requiring her to be suctioned intermittently. The fire department arrived and took over CPR. The ambulance arrived and the resident was taken to the ER. Record review of the Provider Investigation Report dated [DATE] revealed Resident #2 had a history of [REDACTED]. The incident occurred on [DATE]. Under Description of the Allegation it was documented that the resident had nausea and vomiting and requested to go to the hospital. Resident was given [MEDICATION NAME] (a medication for indigestion) and [MEDICATION NAME] (a pain medication). Resident was found unresponsive at 10:50 a.m. Under Description of Injury it was documented that the resident was found unresponsive with no pulse or blood pressure. Her pupils were fixed and dilated. Under Description of Assessment it was documented that vital signs were assessed and CPR initiated. Under Provider Response it was documented that the initial assessment was incomplete because resident request was not honored and physician not notified of change in condition. Record review of the nurses' notes revealed the following entry on [DATE] by LVN A: (No time entered) "Resident up in w/c to D/R for breakfast. Started c/o stomach hurting. [MEDICATION NAME] 30cc P.O. given for discomfort. Vomited small amt. emesis - Resident put back to bed. Positioned on left side - [MEDICAL CONDITION] bag changed, had loose stool." "0930 (9:30 a.m.) C/o stomach still hurting. [MEDICATION NAME] 1 p.o. given (50 mg)." (No time entered) "ADLs done by staff - Foley catheter patent ..." (No time entered) "Fax to Dr.___ about vomiting ask for something else besides [MEDICATION NAME]." Review of a fax to Dr. ___ dated [DATE] (no time) revealed the following: " *comments: (Resident #2) Resident vomited x1 at breakfast table - brought back to room [MEDICATION NAME] was given still complained of pain [MEDICATION NAME] 50 mg 1 p.o. given - Resident had loose stool - [MEDICAL CONDITION] bag was changed. Resident confused at times - Could we have something else for nausea besides [MEDICATION NAME]" Further review of nurses' notes dated [DATE] by LVN A revealed the following: "1050 (10:50 a.m.) Resident sleeping appears to be resting comfortably...resident turned on call light when nurse went to room resident was talking - stated she was SOB. - O2 sat. 98% HOB (elevated) when nurse asked if she wanted to sit up in w/c she acted as if she was going to get out of bed - Ask CNA to help her get up - when CNA entered room resident was not responding - pupils were dilated - Crash cart was brought to room and 911 called. CPR initiated by (ADON 1) and (ADON 2) - Resident vomited large amount brown liquid. Resident suctioned obtained small amt brown liquid - 02 via nasal cannula at 3 LPM - Resident still unresponsive. " "1115 (11:15 a.m.) ___ Ambulance here CPR administered by ___ Ambulance - unable to obtain heart beat. Resident transferred to (hospital)." Review of the hospital emergency room records revealed Resident #2 arrived in theER on [DATE] at 11:35 a.m. with CPR still in progress. The ER physician and staff were unable to revive Resident #2 and she died . Her death was pronounced at 11:46 a.m. During an interview with LVN B on [DATE] at 11:25 a.m. she said she was told on [DATE], around breakfast time, by LVN A that Resident #2 needed something for pain. She said she took the resident an [MEDICATION NAME] but the resident said she couldn't take it because she was nauseated. LVN B said she gave her [MEDICATION NAME] instead at that time and returned later and gave her the [MEDICATION NAME]. LVN B said she started working at the facility a couple of months ago on a prn basis. She said they call her to work if someone calls in. She said she thought [DATE] was only her second time to work in the facility and said she "really didn't know these residents." LVN B did not assess the resident and did not notify the resident ' s physician of her change of condition. During an interview with CNA A on [DATE] at 11:35 a.m. she said Resident #2 didn't want to get up for breakfast that morning ([DATE]). She said she took her breakfast tray to her room but she didn't want anything. She said she was passing the other hall trays when the med nurse (LVN B) told her that Resident #2 had vomited. She said she got CNA B to help her clean up the resident. She said Resident #2 was asking to see the doctor or to go to the hospital. She said as the morning went on she "just wasn't herself." She complained of aching and having mid-abdominal pain. She said "she was not as talkative as usual and was more withdrawn, and she just kept saying she hurt and needed to see the doctor." During an interview on [DATE] at 2:10 p.m. ADON 1 said she was in charge at the facility on [DATE]. She said she was unaware of Resident #2's change of condition or her requests to be sent to the hospital that morning. She said when she responded to the code, Resident #2 was not breathing and had no blood pressure or pulse. She said she initiated CPR and had 911 called. She said they had to interrupt CPR several times to suction dark brown fluid from the resident's mouth. ADON 1 said that her investigation revealed that no one (LVN A, B or C) had notified Resident #2's physician of her change of condition or her requests to be sent to the hospital. She said LVN A had just put a fax in the doctor's box asking for something besides [MEDICATION NAME] for her nausea and vomiting. During an interview with LVN A on [DATE] at 4:30 p.m. she said that on [DATE] around 8:30 a.m. she was told by CNA B that Resident #2 had vomited. She said she asked LVN B (medication nurse) if she had given the resident anything for nausea and that LVN B said she had given her [MEDICATION NAME]. LVN A said she went to the resident's room to check on her and the resident said her stomach was hurting. She had diarrhea in her [MEDICAL CONDITION] bag. LVN A said the resident settled down for a little while but was woke up by hammering in a nearby room that was being renovated. She put on her call light and said she was not feeling good. LVN A said she had faxed the doctor and he would see her when he made rounds. She said Resident #2 did ask to go the hospital but she had only vomited once. She said Resident #2 had so many things wrong with her it was sometimes hard to know what was going on with her. When asked if she assessed the resident that morning she said, "I looked at her, but I don't really remember." When asked if she took the resident's vital signs she said, "I think so. If I did it would be in the nurses' notes." Review of nurses' notes for Resident #2 dated [DATE] revealed the only entries made were by LVN A. No assessment and no vital signs had been documented. During an interview on [DATE] at 1:00 p.m. with Resident #2's physician (facility's Medical Director) he said he was not notified on [DATE] of Resident #2's change of condition or that she was asking to go to the hospital. He said the facility protocol is to send residents to the ER for a change of condition or at the request of the resident. He said the facility should first notify the DON, then the primary physician (or the on- call physician). If a physician cannot be reached the facility knows to call him as, medical director. Review of the facility policy, Significant Change dated ,[DATE], revealed the following: "1. The nursing staff, as well as the interdisciplinary team, will evaluate the patient's/resident's change in status ... 2. The physician, legal representative or appropriate family member will be notified of the change in the patient/resident status when there is: A. An accident resulting in injury and the potential for medical intervention. B. A change in the patient's/resident's physical, mental or psychosocial status ... 3. All significant changes in a patient's/resident's condition will be relayed to the patient's/resident's physician immediately: * If the physician's office is closed, their service will be called; * If contact cannot be made, the Medical Director and Facility Administrator will be notified. * Attempts to reach the physician will continue until the physician is contacted. * All attempts to reach the physician should be thoroughly documented in the medical record." Facility's Plan to Remove Immediate Jeopardy: a) The Interim DON and ADONs will re-educate the licensed nurses regarding performing accurate assessments, documentation of assessments, notification of physician in change of condition, neurological checks and reporting changes in neurological condition during monitoring to the physician. This re-education will begin with the current shift (6:00 p.m. - 6:00 a.m. shift) on [DATE] and oncoming nurses at 5:00 a.m. will be re-educated prior to taking their assignments for their shift. This re-education process will continue throughout the weekend shifts to ensure that licensed nurses caring for the residents have been re-educated as above. A post test will validate staff understanding. The completion date for the re-education will be 6:00 a.m. on [DATE]. b) The Interim DON and ADONs will review the charts of residents with change of conditions to validate that the assessment has been performed, documented, notification of physician occurred, and neurological monitoring (if necessary) have been performed. This chart review will occur each day as part of the nursing leadership meeting Monday through Friday. The nurse managers on duty will check the 24 hour report for any new change of conditions and make observations of the resident to validate that the interventions have been appropriate and documentation reflects care delivered and condition of resident. **Refer to F-9999 for continuation of this deficiency.

Based on observation, interviews and record review the facility failed to ensure each resident received adequate supervision and/or assistive devices to prevent avoidable accidents for one resident (ID# 3 ) of four residents sampled for falls and injury. The facility failed to: thoroughly reassess Resident #3 after an injury , and/or to develop preventive interventions that would help to decrease risk of future incidents. The staff did not put footrests on her wheelchair and a fracture to her left foot resulted. The facility's deficient practice could place any of the 30 residents in the facility identified as requiring assistance with transfers and wheelchair mobility at risk for falls/injuries due to inadequent supervision and preventiative measures. Findings included: RR of the admission record for Resident #3 revealed a [AGE] year old female originally admitted to the facility on [DATE] and latest admit was 01/10/11. Resident #3's [DIAGNOSES REDACTED]. RR of the history and physical dated 01/07/11 revealed under "Physical Examination: Musculoskeletal: Able to move upper extremities, but unable to lift both lower extremities on command, but able to move sideways... unable to lift lower extremities off the bed and she has been bed bound for several months...". RR of the Quarterly MDS assessment dated [DATE] revealed Resident #3's cognitive skills for daily decision making were moderately impaired, meaning she had some difficulty making decisions in new situations only. She was totally dependent for locomotion and for transfers and bathing with 2 person assistance. She had impairment of function of both arms and legs. She required a mechanical lift for transfers. She was 5' 1" tall and weighed 307 pounds. She was receiving Restorative therapy at the facility. RR of the care plans for Resident #3 revealed a care plan updated 03/03/11 addressing the resident's need for extensive to total assistance with ADL's. One of the listed approaches was for the resident to be transferred by Hoyer lift and 2 persons. RR of the care plans for Resident #3 revealed a care plan updated 03/03/11 addressing the resident having short term memory loss which affects her decision making skills. The approaches included to re orient and cue as needed, explain all procedures in terms that she can understand, and information would be repeated as needed. RR of the Central Information Tool for Resident #3 revealed falls as an identified risk, wheelchair and lift as special needs. The Central Information Tools were located in a notebook at the nurses station for all staff to access for information on each resident. The information on the tools included neurological, vision, communication, hearing, skin, gastrointestinal, genitourinary, pain, cardiovascular, respiratory, restorative, identified risks, special needs, rehab, restraints, mood/behavior, and musculoskeletal status. RR of the IR revealed the date of incident was 05/12/11 and the time of the incident was 3:00 p.m. revealed Resident #3 was being pushed in her wheelchair down the hallway. "...Resident put her left leg on floor and it was bent under wheelchair...". Interview with RNA on 05/18/11 at 12:30 p.m. revealed on 05/12/11 she had taken Resident #3 from the dining room after lunch to the therapy room around 12:45 p.m., which is off the dining room. RNA stated Resident #3 had been on Restorative therapy for lower extremities strengthening for about 5 or 6 weeks. She stated Resident #3 did not have foot rests on her wheelchair the day of the incident (05/12/11) , and she just asked the resident to hold her feet up off the floor to be pushed to the therapy room. The therapy lasted approximately an hour, Left extremity Range of Motion, which included marching in place in chair, hip abduction and adduction, ankle pumps and knee replacement exercises. The RNA continued to state, after the therapy around 2:00 p.m. she was pushing Resident #3 back to her room. The RNA stated she asked Resident #3 to pick up her feet, because she did not have any foot rests on her wheelchair. The RNA stated she pushed Resident #3 in her wheelchair across the dining room (approximately 20 feet), out the door, down the hallway (approximately eight feet) and was turning the chair to the right around the corner when Resident #3 stated yelling. RNA stated she was pushing the wheelchair and felt it stop it would not go any further and about that time the resident was moaning. RNA stated she came around to the front of the wheelchair, looked at Resident #3 and noticed her Left foot was turned backwards under the chair with her leg bent under the wheelchair beside the wheel. She stated LVN D looked around the nurses desk saw her and Resident #3 and "...asked what happened and told me to take her to the room...". The RNA stated she leaned Resident #3's wheelchair back a little to lift it up, turned it around backwards, pulled her to her room down the next hall (approximately 50 feet), parked her in her room and left her there. The RNA stated she did not know if the resident was to have foot rest on her wheelchair at all times. She stated the resident can not wheel herself in her wheelchair or move her wheelchair with her feet. She stated sometimes the foot rest are on the chair and sometimes they were not when she came to therapy. The RNA stated she did have a care plan for Resident #3 for her exercises but it does not mention her foot rests, so she would not have any way of knowing if the foot rests were required or not. RR of the nurses notes dated on 05/12/11 at 3:00 p.m. documented, "...Resident now complains of pain states foot is broken - resident put back to bed...order rec'd to X-ray left foot...". The nurses notes revealed Resident #3 was transferred to the emergency room at 7:45 p.m. RR of the X-ray reports dated 05/12/11 revealed the x-rays were done at 5:20 p.m. and revealed "...Oblique fracture of the proximal tibia." RR of the hospital emergency room records revealed Resident #3 was seen at 8:45 p.m. and the results of the X-rays revealed a slanted fracture across the tibia near the ankle. RR of the nurses notes dated 05/13/11 revealed Resident #3 returned to the facility at 12:40 a.m. with orders for pain medication, Foley catheter, elevate leg and follow up with physician. Observed Resident #3 on 05/16/11 at 10:15 lying in bed with head of bed elevated approximately 75 degree angle, neck bent and head on angle and shoulders and body lying on bottom half of bed. Her left leg leg, knee and foot in brace to immobilize the leg. Interview on 05/16/11 at 10:15 a.m. and 12:30 p.m. with Resident #3 revealed ever since her last fracture about a year ago, the facility did use a Hoyer lift to get her in and out of bed. She stated the nurse aides put her in the wheelchair and "...usually put on the foot pedals on the chair...". She stated she did not know why the foot rests were off the wheelchair. Resident #3 stated the nurse aide took her to the dining room for lunch without the foot rests. She stated she held her feet up going to the dining room, but could not coming back because her "...leg hurt...". Resident #3 stated, "... as the girl turned the corner my foot got caught under the wheelchair... I let out a yell...it took her a few minutes to stop...". Resident #3 said she had fractures in the past and she knew it was broken. She stated the nurse did not check her out until she was put back to bed. She stated she did not know at what time. The ADON wrote out a summary of her investigation dated 05/13/11 which revealed Resident #3 being taken back to her room by the RNA around 2:00 p.m. The resident dropped her legs and her foot got caught under the wheelchair as she made a corner. Resident #3 did complain of pain at that time. Two Nurse aides assigned to the residents hall could not find the residents wheelchair foot rests and took her to the dining room without them. LVN D assessed the resident at the time of the incident stated the resident complained of foot pain. After the resident was put to bed the resident complained of leg pain and X-rays were done. The census was 83. There were 30 residents identified by the facility as needing assistance with transfers/supervision to prevent infury.